__________ COURT OF THE STATE OF NEW YORK
COUNTY OF ____________
Index No: __________
_____________________________, Esq., pursuant to CPLR §2106 and under
penalty of perjury, affirms as follows:
1. I am an attorney at law duly licensed to practice in the state of New York and am
representing _______________________ , who is/are the _________________
in the above captioned action.
2. I submit this affirmation together with court papers prepared using the New York
State Unified Court System’s DIY (Do-It-Yourself) Form Program.
3. I am an attorney with _______________________ , which is low-bono program
recognized and authorized to use the DIY Form programs by the NYS Courts
Access to Justice Program.
4. I understand that commercial use of the DIY Form programs is otherwise
5. I have not charged my client for the preparation of the DIY Form program and
have informed my client(s) that use of the DIY Form program is free and that I
am not permitted to charge for its preparation.
6. I am charging my client a reduced fee for representation of any non-DIY Form