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AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form) UNITED STATES DISTRICT COURT for the District of))))) Plaintiff/Petitioner v. Defendant/Respondent
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I present for the record, as of this date, the following statements of facts as to the matters in controversy: 1. The plaintiff/petitioner is a citizen of the United States and has resided in the City of New York (hereinafter “Plaintiff/Petitioner”) for at least a full calendar year, or for the period of twelve months immediately preceding the filing of this action. 2. Prior to the commencement of this action, the plaintiff/petitioner and her minor dependent child resided at the same address. 3. The plaintiff/petitioner began her employment as an office junior level clerk of the City of New York (hereinafter “Defendant/Respondent”) at a specific date prior to the commencement of this action,, September 1, 2007. 4. Prior to the commencement of this action, the plaintiff/petitioner was employed as a clerk for Defendant/Respondent. 5. Plaintiff/Petitioner was promoted to an office position, a position which Plaintiff/Petitioner held on August 18, 2008. 6. The Plaintiff/Petitioner was assigned to an office in the City of New York Building (hereinafter “City”) on December 4, 2009. 7. The plaintiff/petitioner was assigned to an office in the City Building on March 7, 2010. 8. Defendant/Respondent was assigned to an office in the City Building. 9. On January 2, 2010, the defendant/Respondent was assigned to an office in the City Building; however, by that time, the plaintiff/petitioner had been assigned to an office in the City Building. 10. Plaintiff/Petitioner is a resident of the City of New York (hereinafter “Plaintiff/Petitioner”), and is an employee of the City. 11. When Plaintiff/Petitioner worked at the City of New York Office, she was required to provide access to defendant/Respondent to plaintiff/Petitioner's employees, and to defendant/Respondent's employees to defendant/Respondent. 12. Plaintiff/Petitioner is a current resident of the City of New York (hereinafter “City”) and is an employee of the City. 13. Defendant/Respondent did not provide access to plaintiff/Petitioner, and denied access to plaintiff/Petitioner's employees to defendant/Respondent. 14.


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