SAMPLE NEW YORK NOTICEOF FAMILY COURT FORM (FOR EDUCATIONAL PURPOSE ONLY …NOT TO BE USED IN LITIGATION)

SAMPLE NEW YORK NOTICEOF FAMILY COURT  FORM (FOR EDUCATIONAL PURPOSE ONLY …NOT TO BE USED IN LITIGATION)

Form Number

Title

 

 

 

4-1

Petition (For an Order Upon Support Agreement)

4-1a

Summons

4-1b

Summons (Non-Resident)

4-2

Order Upon Support Agreement

4-3

Petition (Individual)

4-3a

Petition (Commissioner)

4-4

Remand Commitment (Undertaking)

4-5+5-1-d

Personal Information Form for Child Support and Paternity Proceedings

4-5a

Undertaking for Support – Cash Deposit

4-6

Temporary Order of Support & Referral to Support Magistrate

4-6a

Referral to Support Magistrate & Temporary Order of Support

4-7

Order of Support

4-7a

Order After Filing of Objections)

4-8

Application for Income Execution for Support Enforcement (Clerk of Court)

4-8b

Petition (To Correct Income Execution for Support Execution for Support Enforcement)

4-8c

Petition (Order to Correct Income Execution for Support Enforcement)

4-9

Income Deduction Order

4-9a

Income Withholding for Support

4-9b

Generic Instructions for Income Withholding Order/ Notice of Support, Application for Child Support Enforcement Services, and Case Registry Filing Form for Use in NYS Family Court and Supreme Court

4-9c

Income Withholding Order/Notice for Support: Additional Information for Non-IV-D Cases

4-10

Qualified Medical Child Support Order

4-11

Petition for Modification of Order of Another Court (Support)

4-11a

Order Modifying Order Made By Another Court (Support)

4-11b

Affidavit in Support of of Modification of Support

4-11v

Verification for Custody/Visitation Modification Petition

4-12

Petition (Violation of Support Order)

4-12a-1

Summons (Violation of Support Order)

4-12a-2

Summons (Violation of Support Order) (Non-Resident)

4-12b

Order of Disposition (Violation of Support Order)

4-12c

Order (Support Magistrate Determination FCA Section 156)

4-13

Petition for Enforcement of Order Made By Another Court (Support)

4-13a

Order Enforcing Order Made By Another Court (Support)

4-13v

Verification for Custody/Visitation Modification Petition

4-14

Order (Entry Money Judgment)

4-15

Petition for Relief From Support Payments And Commitment

4-15a

Order (Relief from Support Payments and Commitment)

4-16

Notice of Motion To Quash, Fix or Modify Conditions of A Child Support Subpoena

4-17

Financial Disclosure Affidavit

4-18

Petition for Support After Acknowledgment of Paternity

4-18a

Petition for Support After Acknowledgement of Paternity (Commissioner)

4-19

Objection to Proposed Adjusted Order

4-19a

Order Determining Objection to Proposed Adjustment

4-19b

Order Determining Objection to Adjusted Order (Cost of Living Adjustment)

4-20

Motion to Vacate Adjusted Order of Support

4-20a

Affidavit in Support of Motion to Vacate Adjusted Order of Support

4-21

Enforcement of Arrears – Order to Licensing Entity

4-21a

Order to Licensing Entity to Terminate Suspension

4-22

Objection to Support Collection Unit Denial of Challenge to Driver’s License Suspension

4-22a

Enforcement of Arrearages – Determination of Objections

4-23

Qualified Domestic Relations Order

4-24
5-16
UIFSA-10

Electronic Testimony Application

Form 4-24a
5-16a
UIFSA-10a

Support, Paternity, UIFSA–Order on Electronic Testimony Application

4-25a

Child Support — Motion to Vacate for Lack of Service

4-25b

Child Support — Affidavit in Support of Motion to Vacate for Lack of Service

4-26

Child Support –Order on Motion to Vacate for Lack of Service

4-SM-1

Stipulation for Child Support

4-SM-2

Information Concerning Filing of Objections And Rebuttal in A Proceeding Before A Support Magistrate

4-SM-3

Findings of Fact

F.C.A. §§ 413, 416, 424, 425;                                                                                               Form 4-1

SSL§ 111-g                                                                                                                 (Support–Petition for an

[NOTE: Personal  Information Form 4-5/5-1-d,                                                          Order Upon Support

containing social security numbers of parties and                                                    Agreement)

dependents, must be filed with this Petition]                                                                           6/2012

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

…………………………………………………………………..

In the Matter of Petition for an Order

Upon an Agreement of Support, between                                                              Docket No.

(Commissioner of Social Services, Assignee

on behalf of                                        , Assignor)

Petitioner,                                                                                          PETITION

(For an Order Upon

-against-                                                                                                                              Support Agreement)

Respondent

…………………………………………………………………..

The Petitioner respectfully alleges that:

1.  Petitioner (resides at) (official address is)[specify]:[1]

and the Respondent resides at

2.  Petitioner and Respondent have entered into a written agreement for the support of

Name                                                          Age      Date of Birth

Spouse:

Child(ren):

in the amount of [specify]:                                                   .  A true copy of said agreement for support is attached hereto and made a part hereof, which agreement contains a provision stating that the parties have been advised of the provisions of section 413, subdivision 1, of the Family Court Act.

3.  Petitioner and Respondent have consented to the entry of an order by this Court upon the agreement for support.

4. [Applicable to individual petitioner; if not applicable, SKIP to ¶5;  check applicable box]:

□ I have applied for child support services with the local Department of Social Services.

□ I am now requesting child support services by the filing of this Petition.[2]

□ I have continued to receive child support services after the public assistance or care case has

closed.

□ I do not wish to make application for child support services.

□ I am not eligible for child support enforcement services).  [Petitioners seeking only spousal support are ineligible.]

5.  Respondent □ had □ did not have a prior order of support that was  payable through the Support  Collection Unit.

6. No previous application has been made to any judge or court, including a Native American tribunal,  or is presently pending before any judge or court, for the relief requested in this petition (except

WHEREFORE, the Petitioner requests that the agreement of support annexed to this petition be approved and confirmed pursuant to Article 4 of the Family Court Act and that an order of support upon the agreement be entered by this Court and that Respondent be required to exercise the option of additional coverage for health insurance in favor of (his)(her) spouse and above-named  child(ren).

NOTE:          (1)  A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) SHALL BE ADJUSTED BY THE APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT  SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE COURT WILL  CONSIDER IN ADJUSTING THE  CHILD SUPPORT ORDER IN ACCORDANCE  WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT.

(2)  A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVING FAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY.  ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER.

(3)  WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS, AS REQUIRED BY SECTION FOUR HUNDRED FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTED OCCURRING ON OR AFTER THE EFFECTIVE

DATE OF THE ADJUSTED ORDER, REGARDLESS OF WHETHER OR  NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER.

_____________________________

Petitioner

_____________________________

Print or type name

_____________________________

Signature of Attorney, if any

_____________________________

Attorney’s Name (Print or Type)

_____________________________

_____________________________

Attorney’s Address and Telephone Number

F.C.A.§§413, 424-a, 426, 427, 433, Art.5-B                                     Form 4-la

(TO BE USED FOR SERVICE                                                      (Summons-Support)

WITHIN NEW YORK STATE)                                                     8/2010

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

……………………………………………………………………………

In the Matter of a Proceeding Under                                                 Docket No.

Article           of the Family Court Act

(Commissioner of Social Services, Assignee

on behalf of                              , Assignor

 

                                                                                                SUMMONS

                                               Petitioner                                    — SUPPORT

-against-

                                                    Respondent

………………………………………………………………………………

NOTICE:YOUR FAILURE TO APPEAR MAY RESULT IN SUSPENSION OF YOUR          DRIVING PRIVILEGES; STATE-ISSUED PROFESSIONAL, OCCUPATIONAL                            AND BUSINESS LICENSES; AND RECREATIONAL AND SPORTING LICENSES                      AND PERMITS.[3]  FURTHER, YOUR FAILURE TO APPEAR WILL RESULT IN                            THE ENTRY OF AN ORDER ON DEFAULT UNLESS SERVICE HAS BEEN                                 MADE BY MAIL ALONE, IN WHICH EVENT NO DEFAULT MAY BE                                          ENTERED WITHOUT PROOF SATISFACTORY TO THE COURT THAT YOU                             HAVE RECEIVED ACTUAL NOTICE OF THE COMMENCEMENT OF THIS                                PROCEEDING.  YOU ARE FURTHER ADVISED THAT, UPON YOUR                                          APPEARANCE ON THE RETURN DATE OF THIS SUMMONS, YOU MUST                                PROVIDE PROOF OF YOUR INCOME AND ASSETS AND A TEMPORARY OR                         PERMANENT ORDER OF SUPPORT WILL BE ISSUED. YOU HAVE A RIGHT                           TO BRING  A LAWYER WITH YOU, IF YOU CHOOSE.

BY ORDER OF THE FAMILY COURT OF THE STATE OF NEW YORK

TO THE ABOVE-NAMED RESPONDENT: _______________________________, who resides or is                     found at:                                                                                                    .

A petition under Article          of the Family Court Act having been filed with this Court, and annexed hereto,

YOU ARE HEREBY SUMMONED to appear before the Family Court at ___________________________________________, New York, on               ,            at      o’clock in  ☐ morning  ☐afternoon of that day to answer the petition and to be dealt with in accordance with Article __ of the Family Court Act.

On your failure to appear as herein directed, a warrant may be issued for your arrest.

You must provide the court with proof of your income and assets by _________________

                                                ,         , on the attached form provided for that purpose.  You are required to attach a current and representative paycheck stub and most recently filed state and federal income tax returns to said form, including a copy of the W-2 wage and tax statement(s) submitted with the returns.  You may be required to furnish past and present income tax returns; employer statements; pay stubs; corporate, business or partnership books and records; corporate and business tax returns; and receipts for expenses or such other measures of verification as the Court determines appropriate.

Dated:                          ,          .

_______________________________

Clerk of the Court

NOTICE:  Family Court Act §154(c)  provides that support, paternity, custody, family offense      and child abuse and neglect petitions, in which an order of protection is sought or in              which a violation of an order of protection is alleged, may be served outside the State              of New York upon a Respondent who is not a resident or domiciliary of the State of                New York.  In such   instance, the exercise of personal jurisdiction over the                              Respondent is limited to the issue of  the request for, or alleged violation of, the                       order of protection, unless other grounds exist for the exercise of personal                                jurisdiction over the Respondent.  Where the Respondent has been served with this                  summons and petition and does not appear, the Family Court may proceed to a                         hearing with respect to issuance or enforcement of the order of protection.

F.C.A. §§ 413, 416, 424, 425,                                                                          Form 4-2

439, 439(a), 440, 449; D.R.L. § 240                                                            (Order on Support Agreement)

6/2012

At a term of the Family Court of

the State of New York, held in and

for the County of                           ,

at                                      , New York,

on                                 .

PRESENT:  Hon. ______________________________

Judge/Support Magistrate

……………………………………………………………………………

In the Matter of the Petition for an Order

upon an Agreement of Support, between

Docket No.

(Commissioner of the Social Services, Assignee

on behalf of                                  , Assignor)

S.S.#: xxxx-xx-              

Petitioner,                                                                   ORDER UPON

SUPPORT

AGREEMENT

-against-

Respondent.

S.S.#: xxxx-xx-             

……………………………………………………………………………

NOTICE:          YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN      INCARCERATION FOR CRIMINAL NON-SUPPORT OR CONTEMPT;         SUSPENSION OF YOUR DRIVER’S LICENSE, STATE-ISSUED                 PROFESSIONAL, TRADE,  BUSINESS AND OCCUPATIONAL LICENSES

AND RECREATIONAL AND SPORTING LICENSES AND PERMITS; AND            IMPOSITION OF REAL OR PERSONAL PROPERTY LIENS.

IF THIS ORDER IS ENTERED BY A JUDGE, PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY             APPELLANT IN COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, WHICHEVER IS EARLIEST.

IF THIS ORDER IS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTEN OBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYS OF THE DATE THE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IF THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER.[4]

A petition having been filed by the above-named Petitioner for the issuance of an order upon an agreement for support made between the Petitioner and the above-named Respondent dated

; and

The petition having been heard by this Court; and the Petitioner having appeared  ☐ with counsel ☐ without counsel and Respondent having appeared ☐ with counsel ☐without counsel; and

And the Court finds further that [check applicable box]:

□ The non-custodial parent’s pro rata share of the basic child support obligation is neither unjust nor inappropriate;

□ Upon consideration of the following factors specified in Family Court Act §413(1)(f): the non-custodial parent’s pro rata share of the basic child support obligation is □ unjust

□ inappropriate for the following reasons [specify]: [5]

And the Court finds further that the parties have voluntarily stipulated to child support for the following child(ren)[specify]:                                                                              payable by [specify]:

to [specify]:                                                                 in the amount of $           □ weekly  □ every two weeks □ monthly □twice per month □ quarterly.

This stipulation has been entered into the record and recites, in compliance with Section 413(1)(h) of the Family Court Act, that:

a. The parties have been advised of the provisions of Section 413(1)of the Family Court Act;

b.  The unrepresented party, if any, has received a copy of the child support standards chart promulgated by the Commissioner of the N.Y.S. Office of Temporary and Disability Assistance pursuant to Section 111-i of the Social Services Law;

c.  The basic child support obligation as defined in Family Court Act Section 413(1) presumptively results in the correct amount of child support to be awarded;

d.  The basic child support obligation in this case is $__________ □ weekly  □ every two weeks □ monthly □twice per month □ quarterly; and

e.  The parties’ reason(s) for agreeing to child support in an amount different from the basic child support obligation (is) (are) [specify]:

;

The Court approves the parties’ agreement to deviate from the basic child support obligation for the following reasons: [specify; see Family Court Act§ 413(1)(f)]:

;

The name, address and telephone number of Respondent’s current employer(s) is/are:

NAME                          ADDRESS                                                         TELEPHONE

NOW, therefore, it is hereby

ORDERED that the agreement for support annexed to the petition is approved; and it is further

ORDERED that pursuant to the annexed agreement for support, the above-named Respondent shall make payments ☐ weekly, ☐ every two weeks, ☐monthly, ☐twice per month, and ☐ quarterly as follows:

Name                             Date of Birth            Last 4 Digits of Soc. Sec. #              Amount

Spouse:

Child(ren):

Total:

and it is further

ORDERED that, pursuant to Domestic Relations Law §236(B)(1)(a), payments for the support of the spouse shall terminate upon death of the spouse, upon the spouse’s valid or invalid marriage or upon modification in accordance with Domestic Relations Law §236(B)(9) or 248, and it is further

ORDERED and ADJUDGED that the above-named Respondent is responsible for the support so ordered from                                , the date the petition was filed to the date of this Order,  less the amount of $                      already paid, and that the Respondent shall pay the sum of $                 as follows: $                     immediately, $                      ☐ weekly, ☐ every two weeks, ☐ monthly, ☐ twice per month,   ☐ quarterly; and it is further

ORDERED that commencing on _________________the above-named Respondent, upon notice of this Order, pay or cause the above amount(s) to be paid to [check applicable box]:

□ Petitioner by cash,   check or  money order

□ Non-IV-D cases: Payable to the Petitioner by check or money order and mailed to the NYS Child Support Processing Center,  P. O. Box 15365, Albany, NY 12212-5365. The county name for the matter must be included with the payment for identification purposes.  

□ IV-D cases: Payable by check or money order made payable to and mailed to the NYS Child Support Processing Center, PO Box 15363, Albany, NY 12212-5363. The county name and New York Case Identifier number for the matter must be included with the payment for identification purposes; and it is further

ORDERED that, pursuant to Family Court Act §440(1)(b)(2), this order shall be enforceable by immediate income deduction order issued in accordance with Section 5242 (c) of the Civil Practice Law and Rules; and it is further

[Check box if applicable]

☐ ORDERED that, for the following reason(s) [specify]:

constituting good cause pursuant to Family Court Act §440(1)(b), the  ☐ IV-D cases: Support Collection Unit ☐ Non IV-D cases: Court  shall NOT ISSUE an immediate income execution; however, in the event of default,[6]this order shall be enforceable pursuant to Section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; (and it is further)

[IV-D cases only]:□ ORDERED that the Respondent, custodial parent and any other individual parties immediately notify the Support Collection Unit of any changes in the following information: residential and mailing addresses, social security number, telephone number, driver’s license number; and name, address and telephone numbers of the parties’ employers and any change in health insurance benefits, including any termination of benefits, change in the health insurance benefit carrier, premium, or extent and availability of existing or new benefits; and it is further

☐ ORDERED that pursuant to the agreement for support the                                                  pay to                         ,

the attorney for the other party, the sum of $                 as and for counsel fees in this proceeding, which payment may be made in the amount of $            ☐ weekly, ☐ every two weeks, ☐ monthly, ☐ twice per month, ☐ quarterly, commencing on               ,         , until the entire sum is paid;

And the Court having determined that [check applicable box]:

□ The child(ren) are currently covered by the following health insurance plan [specify]:

which is maintained by [specify party]:

□ Health insurance coverage is available to one of the parents or a legally-responsible relative       [specify name]:                                     under the following health insurance plan [specify, if known]:        ,       which provides the following health insurance benefits [specify extent and type of benefits, if                      known, including any medical, dental, optical, prescription drug and health care services or other                        health care benefits]:

□ Health insurance coverage is available to both of the parents as follows:

Name    Health Insurance Plan     Premium or Contribution                                                    Benefits

□ No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren)            may be eligible for health insurance benefits under the New York “Child Health Plus” program or the New York State Medical Assistance Program, or the publicly funded health insurance program in the  State where the custodial parent resides.

□ No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) are currently enrolled in the New York State Medical Assistance Program,

IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]:

□ continue to maintain health insurance coverage for the following eligible dependent(s) [specify]:                                   under the above-named existing plan for as long as it remains available;

□ enroll the following eligible dependent(s) [specify]:

under the following health insurance plan [specify]:

immediately and without regard to seasonal enrollment restrictions and maintain such coverage as long as it remains available in accordance with

[IV-D cases]:  □ the Medical Execution, which shall be issued immediately by                                   the Support Collection Unit, pursuant to CPLR 5241

□ the Medical Execution issued by this Court

[Non-IV-D cases]:  □ the Qualified Medical Child Support Order.

Such coverage shall include all plans covering the health, medical, dental, optical and prescription drug needs of the dependents named no change and any other health care services or benefits for which the legally-responsible relative is eligible for the benefit of such dependents; provided, however, that the group health plan is not required to provide any type or form of benefit or option not otherwise provided under the group health plan except to the extent necessary to meet the requirements of Section 1396(g-1) of Title 42 of the United States Code.  The legally-responsible relative(s) shall assign all insurance reimbursement payments for health care expenses incurred for ☐ his ☐ her eligible dependent(s) to the provider of such services or the party having actually incurred and satisfied such expenses, as appropriate;

OR

□ IT IS THEREFORE ORDERED that the custodial parent [specify name]:                                                                  shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus” program (the NYS health insurance program for children) and the New York State Medical Assistance Program or the publicly funded health insurance program in the  State where the custodial parent resides.

And the Court further finds that:

The mother is the ☐ custodial ☐non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is                                             ;

The father is the ☐ custodial ☐ non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is                                               ;

And the Court further finds that [check applicable box];

□ Each parent shall pay the cost of premiums or family contribution in the same proportion as each of their incomes are to the combined parental income as cited above;

□ Upon consideration of the following factors [specify]:

pro-rating the payment would be unjust or inappropriate for the following reasons [specify]:

Therefore, the payments shall be allocated as follows [specify]:   ,

; and it is further

OR

 

            □ [Where the child(ren) are recipients of managed care coverage under the New York State Medical Assistance Program] ORDERED that                              , the non-custodial parent herein, shall pay the amount of $            per                    toward to the managed care premium under the New York State Medical Assistance Program;

□ [Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that                                        , the non-custodial parent herein, shall pay up to an annual maximum of $                      for the current calendar year to the New York State Medical Assistance Program upon written notice that the program has paid health care expenses on behalf of the child(ren) for costs incurred during the current calendar year.

□ [Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that                                   , the non-custodial parent herein, pay as part of the cash medical support obligation up to an annual maximum of $                                for the calendar year commencing January 1,             and for every year thereafter to the New York State Medical Assistance Program upon written notice that the Medicaid program has paid health care expenses on behalf of the child(ren).

□ ORDERED that                                              , the non-custodial parent herein, shall pay the amount of $                       , representing his/her share of premiums and/or costs incurred by the New York State Medical Assistance Program for the period of time from                                     to the date of this order, which amount shall be support arrears/past due support;

□ ORDERED that in the event that the child(ren) cease(s) to be enrolled in the New York State Medical Assistance Program, the non-custodial parent’s obligation to pay his/her share of managed care coverage premiums and/or fee-for-service reimbursement shall terminate as of the date the child(ren) is/are no longer enrolled in Medicaid;

            ORDERED that the legally responsible relative immediately notify the [check applicable box]: □ other party (non-IV-D cases)   □ Support Collection Unit (IV-D cases)  of any change in health

insurance benefits, including any termination of benefits, or change in the health insurance benefit carrier or premium, or extent and availability of existing or new benefits; and it is further

ORDERED that [specify name]:                                         shall execute and deliver to [specify name]:                                                        any forms, notices, documents, or instruments to assure timely payment of any health insurance claims for said dependent(s); and it is further

ORDERED that upon a finding that the above-named legally-responsible relative(s) willfully failed to obtain health insurance benefits in violation of [check applicable box(es)]:  □ this order

□ the medical execution  □ the qualified medical child support order, such relative(s) will be presumptively liable for all health care expenses incurred on behalf of the above-named defendant(s) from the first date such dependent(s) ☐was ☐were  eligible to be enrolled to receive health insurance benefits after the issuance of such order or execution directing the acquisition of such coverage; and it is further

ORDERED that [specify]:                                                             the legally-responsible relative(s) herein, shall pay (his)(her) pro rata share of future reasonable health expenses of the child(ren) not covered by insurance by [check applicable box]: □ direct payments to the health care provider □ other [specify]:

; and it is further

ORDERED that, if health insurance benefits for the above-named child(ren) not available at the present time become available in the future to the legally-responsible relative(s), such relative(s) shall enroll the dependent(s) who are eligible for such benefits immediately and without regard to seasonal enrollment restrictions and shall maintain such benefits so long as they remain available;  and it is further

[Check applicable box(es)]:

□ ORDERED that                                                                              , the non-custodial parent herein, pay the sum of $                              as (his)(her) proportionate share of reasonable child care expenses, to be paid as follows:

; and it is further

□ ORDERED that                                           , the non-custodial parent herein, pay the sum of $                                                as educational expenses by  □ direct payment to the educational provider   □ other [specify]:

;  and it is further

□ ORDERED that [specify party or parties; check applicable box(es):

□          purchase and maintain □ life  and/or  □ accident insurance policy in the

amount of [specify]:                                                and/or

□          maintain the following existing  □ life  and/or  □ accident insurance policy in the

amount of [specify]:                                                and/or

□          assign the following as □ beneficiary  □ beneficiaries [specify]:                                   

to the following existing  □ life  and/or  □ accident insurance policy or policies

[specify policy or policies and amount(s)]:                                                                  .

In the case of life insurance, the following shall be designated as irrevocable beneficiaries [specify]:                                              during the following time period [specify]:                                    

In the case of accident insurance, the insured party shall be designated as irrevocable beneficiary during the following time period [specify]:                                                             .

The obligation to provide such insurance shall cease upon the termination of the duty of [specify party]:                                                    to provide support for each child;. and it is further

□ ORDERED that the support obligor, the non-custodial parent, is directed to:[7]

□ seek employment

□ participate in job training, employment counseling, or other programs designed to lead to employment [specify program]:

[IV-D Cases]:  □  ORDERED that when the person or family to whom family assistance is being paid no longer receives family assistance, support payments shall continue to be made to the Support Collection Unit, unless such person or family requests otherwise; and it is further

[Judicial orders only] □  ORDERED that Respondent shall have the following rights of visitation with respect to the child(ren)[specify]:

[REQUIRED]   IT IS FURTHER ORDERED that a copy of this order be provided promptly by [check applicable box]:□ Support Collection Unit ((IV-D cases: )  □ Clerk of Court (non-IV-D cases) to the New York State Case Registry of Child Support Orders established pursuant to Section 111-b(4-a) of the Social Services Law;  and it is further

ORDERED that [specify]:

ENTER

                                                                                    

□ Judge of the Family Court □ Support Magistrate

Dated:              ,        .

Check applicable box:

☐ Order mailed on [specify date(s) and to whom mailed]:______________________

☐ Order received in court on [specify date(s) and to whom given]:________________

NOTE:       (1)  THIS ORDER OF CHILD SUPPORT SHALL BE ADJUSTED BY THE         APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER THIS ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH  ( 2) BELOW. UPON APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT, AN ADJUSTED ORDER  SHALL BE SENT TO THE PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THIRTY-FIVE (35) DAYS FROM THE DATE  OF MAILING TO SUBMIT A WRITTEN OBJECTION TO THE COURT INDICATED  ON SUCH ADJUSTED ORDER.  UPON RECEIPT OF SUCH WRITTEN OBJECTION,  THE COURT SHALL SCHEDULE A HEARING AT WHICH THE PARTIES MAY BE PRESENT TO OFFER EVIDENCE WHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH THE CHILD SUPPORT STANDARDS ACT.

(2)  A RECIPIENT OF FAMILY ASSISTANCE SHALL HAVE THE CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH  ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED WITHOUT FURTHER APPLICATION OF ANY PARTY.  ALL PARTIES WILL RECEIVE NOTICE OF ADJUSTMENT FINDINGS.

(3)  WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY    CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS TO WHICH AN ADJUSTED ORDER CAN BE SENT AS REQUIRED BY SECTION 443 OF THE FAMILY COURT ACT, THE SUPPORT OBLIGATION AMOUNT  CONTAINED THEREIN SHALL BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTED OCCURRING OR AFTER THE EFFECTIVE DATE OF THE ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER.

(4)  IN ADDITION TO A COST OF LIVING ADJUSTMENT, EACH PARTY HAS RIGHT TO SEEK A MODIFICATION OF THE CHILD SUPPORT ORDER UPON A SHOWING OF: (I) A SUBSTANTIAL CHANGE IN CIRCUMSTANCES; OR (II) THAT THREE YEARS HAVE PASSED SINCE THE ORDER WAS ENTERED, LAST MODIFIED OR ADJUSTED; OR (III) THERE HAS BEEN A CHANGE IN EITHER PARTY’S GROSS INCOME BY FIFTEEN PERCENT OR MORE SINCE THE ORDER WAS ENTERED, LAST MODIFIED, OR ADJUSTED; HOWEVER, IF THE PARTIES HAVE SPECIFICALLY OPTED OUT OF SUBPARAGRAPH (II) OR (III) OF THIS PARAGRAPH IN A VALIDLY EXECUTED AGREEMENT OR STIPULATION, THEN THAT BASIS TO SEEK MODIFICATION DOES NOT APPLY.

S.S.L§§ 111-g; F.C.A; 416, 421, 422,                                                                                           Form 4-3

423; CPLR 5242                                                                                                                              (Support–Petition–

[NOTE: Personal Information Form 4-5/5-1-d,                                                                     Individual)

containing social security numbers of parties and                                                                              6/2012

dependents, must be filed with this Petition]

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

………………………………………………………………………

In the Matter of a Proceeding for Support

Under Article 4 of the Family Court Act                                                                                  Docket No.

Petitioner,

SUPPORT

-against-                                                                                                                              PETITION

(Individual)

Respondent.

……………………………………………………………………..

TO THE FAMILY COURT:

The undersigned Petitioner respectfully alleges that:

1.  a. I  reside at [specify]:[8]                                                                                                                                    b. Respondent resides at [specify]:[9]

2.  I  am authorized to originate this proceeding because [check applicable box(es)]:

□  Respondent and I were married at                                on

□  Respondent and I have the child(ren) named below in common

□  Other [specify Petitioner’s relationship to child(ren)]:

3.  Respondent is chargeable with the support of the following spouse and dependent(s):

Name                                                              Date of Birth

 

Spouse:

Child(ren):

4. [Check applicable box(es); if children have different fathers, include separate paragraphs]:

□ The father of the of the above-named child(ren) is [specify]:                               .

□ The father was married to the child(ren)’s mother at the time of the conception or birth.

□ An order of filiation was made on [specify date and court and attach true copy]:

□ An acknowledgment of paternity was signed on [specify date]:                                  by                   [specify who signed and attach a true copy]:

□ The father is deceased.

□ The father of the below-named child(ren) has not been  legally established.

□ A paternity agreement or compromise was approved by the Family Court of [specify county]:                       County on                 ,              , concerning [name parties to agreement or compromise and child(ren)]:                                             .  A true copy of the agreement or compromise is attached.

5. [Applicable to cases in which mother is not a party]: The name and address of the mother is [indicate if deceased or if address ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]:

6.  (Upon information and belief), Respondent, on or about                 ,       , and thereafter, has failed to provide fair and reasonable support for Petitioner and the dependent(s) according to Respondent’s means and earning capacity.

7. [Check applicable box(es); if not applicable, SKIP to ¶8]:   Respondent is unlikely to make payments in accordance with the order of support requested, because of  □ past lack of financial responsibility

□ credit references   □ credit history    □ other [specify]:

8.  [Check applicable box(es); if not applicable, SKIP to ¶9]: Respondent has an

□ employer   □ income payor,  as defined in Civil Practice Law and Rules 5241(a), whose address is [specify]:                                                                               , as a source of income.

9. [Check applicable box]:

□ I have applied for child support services with the local Department of Social Services.

□ I am now requesting child support services by the filing of this Petition.[10]

□ I have continued to receive child support services after the public assistance or care case has

closed.

□ I do not wish to make application for child support services.

□ I am not eligible for child support enforcement services).  [Petitioners seeking only spousal support are ineligible.]

10.  Respondent □ had □ did not have a prior order of support that was  payable through the Support  Collection Unit.

11.No previous application has been made to any judge or court, including a Native American tribunal,  or is presently pending before any judge or court, for the relief requested in this petition (except

WHEREFORE, I am requesting that this Court issue an order of support directing Respondent to pay fair and reasonable support, that Respondent be required to exercise the option of additional coverage for health insurance in favor of (his) (her) spouse and above-named child(ren), and for such other and further relief as the law provides.

NOTE: (1)  A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) SHALL BE ADJUSTED BY THE APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT.

(2)  A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVING FAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY.  ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER.

(3)  WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS, AS REQUIRED BY SECTION FOUR HUNDRED FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OF THE ORDER OF SUPPORT WHICH WAS

REVIEWED AND ADJUSTED OCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ADJUSTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER.

Dated:

____________________________

Petitioner

____________________________

Print or type name

____________________________

Signature of Attorney, if any

____________________________

Attorney’s Name (Print or Type)

____________________________

____________________________

____________________________

Attorney’s Address and Telephone Number

F.C.A. §§ 415, 416, 421, 422,                                                                                           Form 4-3a

432, 424, 571; S.S.L. §§ 101, 102                                                                                     (Support)

C.P.L.R. 5242                                                                                                                     6/2012

[NOTE: Personal Information Form 4-5/5-1d,

containing social security numbers of parties and

dependents, must be filed with this Petition]

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

………………………………………………………………………..

In the Matter of a Proceeding for                                                                                                                                                                                                                                               Docket No.

Support under Article 4 of the Family Court Act

(Commissioner of Social Services,  Assignee

on behalf of                                               , Assignor)

Petitioner,                                                                                   PETITION

(Commissioner)

-against-

Respondent.

…………………………………………………………………

TO THE FAMILY COURT:

The undersigned Petitioner respectfully alleges that:

1.  Petitioner is Commissioner of Social Services whose official address is                                  in the County of                   , State of New York and is authorized to originate this proceeding (as assignee) pursuant to the Social Services Law and the Family Court Act of the State of New York.

2.  The assignor is authorized to originate a support proceeding but has assigned her/his right to do so to the Commissioner of Social Services pursuant to the Social Services Law of the State of New York. In the event the assignment ends the assignor may pursue support and may seek an order of support.

3.  (Upon information and belief) (Assignor) and Respondent were married at

on                 ,      .)

4.  Respondent is chargeable with the support of   the following:

Name                                                                          Date of Birth

Spouse:

Child(ren)

5.  (Upon information and belief) Respondent, on or about                  ,   , and since that date,  has failed to provide fair and reasonable support for the above-named dependent(s) according to Respondent’s means and earning capacity.

[Check boxes if applicable; delete paragraphs 5 and/or 6  if inapplicable]:

6.Respondent is unlikely to make payments in accordance with the order of support requested, because of  □ past lack of financial responsibility

□ credit references   □ credit history    □ other [specify]:

7. Respondent has the following source of income:   □employer   □income payor,  as defined in CPLR Sec.5241(a), whose name and address are   [specify]:

8. No previous application has been made to any judge or court, including a Native American tribunal,  or is presently pending before any judge or court, for the relief requested in this petition (except

WHEREFORE, Petitioner requests an order for support[11] directing Respondent to pay fair and reasonable support payable to the Commissioner of Social Services or, in the event that the assignment ends, payable to the ex-assignor, requiring  Respondent to exercise the option of additional coverage for health insurance in favor of (his) (her) above-named child(ren), and for such other and further relief as the law provides.

NOTE: (1)  A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) SHALL BE ADJUSTED BY THE APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT.

(2)  A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVING FAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY.  ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER.

(3)  WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS, AS REQUIRED BY SECTION FOUR HUNDRED

FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING

ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTED OCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ADJUSTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER.

______________________________________

Petitioner

______________________________________

Print or type name

______________________________________

Signature of Attorney, if any

______________________________________

Attorney’s Name (Print or Type)

______________________________________

______________________________________

______________________________________

Attorney’s Address and Telephone Number

F.C.A §§ 432, 435(b), 439, 439(a), 528,                                                                                           Form 4-4

Art.5-B                                                                                                                                        (Remand Commitment-

Undertaking)

8/2010

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

……………………………………………………………………………

In the Matter of the Proceeding for Support under

Article (4)(5)(5-B) of the Family Court Act                                                                                                                                                   Docket No.

Petitioner                                                                            REMAND

COMMITMENT

-against-                                                                                                              (Undertaking)                                                   Respondent

……………………………………………………………………………

TO ANY PEACE OFFICER OF THE STATE OF NEW YORK AND TO THE SHERIFF of the JAIL of                                                                          COUNTY:

The above-named Respondent having been brought before this Court upon a petition filed under Article  ☐4  ☐5   ☐5-B of the Family Court Act, alleging that the Respondent is chargeable with the support of certain alleged dependents;

And the Respondent having thereupon been duly held for further proceedings to be held on                  ,      ,  (s)he is required to furnish an Undertaking in the sum of $                  with sufficient surety approved by the Court, for (his)(her) appearance on that date and in default thereof (s)he is hereby committed to the custody of the above-named Sheriff or Warden until said date unless sooner discharged according to law;

AND YOU ARE, THEREFORE, COMMANDED forthwith to take charge of the above-named Respondent and deliver (him)(her) into the care and custody of the said Sheriff or Warden.

______________________________

Judge of the Family Court

____________________________________________________________________________

Docket No.                                                             (Prison)(Jail)

(County)(City)(Town) of

TO THE FAMILY COURT,                                                                   COUNTY.

This is to acknowledge receipt of the body of

committed hereto on the annexed Commitment under

Article  ☐4  ☐5   ☐5-B of the Family Court Act.

Date:                            Time:                           a.m.         p.m.

___________________________

Sheriff or Warden

NOTE: This form must be filed with                                                                                                                                                             FORM 4-5/5-1-d

              all child support and paternity petitions.                                                             8/2010

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

………………………………………………………………………

In the Matter of a Proceeding for Support

Under Article  □4  □5 of the Family Court Act                                                                                       Docket No.

PERSONAL

                                                                                                                                                                                                INFORMATION FORM

Petitioner,                                                                                                                          □ Child Support

□ Paternity

-against-

Respondent.

……………………………………………………………………….

NOTICE: You must include your full social security number and those of your children on this form. Social security numbers are confidential and will be disclosed only as required by law. If disclosure of your address and telephone number would pose an unreasonable health or safety risk to you or your children, you may request address confidentiality by filling out  General Form GF-21 (Address Confidentiality Affidavit), which is available on-line at www.nycourts.gov.

 

NAME OF PETITIONER OR ASSIGNOR:[12] ______________________________________________________

ADDRESS (required):                      __________________________________________________________________

__________________________________________________________________

Should your address be kept confidential from the other party:   Yes   □    No □

TELEPHONE NUMBER:                   HOME: _______________  WORK: ______________  CELL: ______________

Should your phone number be kept confidential from the other party:   Yes   □    No □

SOCIAL SECURITY NUMBER (required): __________________     DATE OF BIRTH: _____________________

EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______                                       (M or F)

EMPLOYER NAME: _______________________________________________________________________

ADDRESS: _______________________________________________________________________________

RESPONDENT’S NAME:                 __________________________________________________________________

ADDRESS (required):                      __________________________________________________________________

__________________________________________________________________

TELEPHONE NUMBER:                   HOME: _______________  WORK: ______________  CELL: ______________

SOCIAL SECURITY NUMBER: _________________________ DATE OF BIRTH: _____________________

EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______                                       (M or F)

EMPLOYER NAME: _______________________________________________________________________

ADDRESS: _______________________________________________________________________________

Children(s) Names Date of Birth             Social Security Number   (M or F)

List any other names you or the other party may have been previously known by (i.e., maiden name, previous marriage name, etc.)

PETITIONER: _____________________________________________________________________________

RESPONDENT: ___________________________________________________________________________

ARE YOU SCHEDULED IN ANY OTHER COURT OR CASE WITH THE PERSON YOU ARE FILING AGAINST?    □ YES – Court:__________________County:  ________________

                                                                              Docket or index number: __________________________

                                                                              Date of next appearance: __________________________                                                                   NO                              

Dated:

____________________________

Signature of Petitioner

____________________________

Print or type name

____________________________

Signature of Attorney, if any

____________________________

Attorney’s Name (Print or Type)

____________________________

____________________________

____________________________

Attorney’s Address & Telephone Number

NOTE: This form must be filed with                                                                                                                                                             FORM 4-5/5-1-d

              all child support and paternity petitions.                                                             8/2010

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

………………………………………………………………………

In the Matter of a Proceeding for Support

Under Article  □4  □5 of the Family Court Act                                                                                       Docket No.

PERSONAL

                                                                                                                                                                                                INFORMATION FORM

Petitioner,                                                                                                                          □ Child Support

□ Paternity

-against-

Respondent.

……………………………………………………………………….

NOTICE: You must include your full social security number and those of your children on this form. Social security numbers are confidential and will be disclosed only as required by law. If disclosure of your address and telephone number would pose an unreasonable health or safety risk to you or your children, you may request address confidentiality by filling out  General Form GF-21 (Address Confidentiality Affidavit), which is available on-line at www.nycourts.gov.

 

NAME OF PETITIONER OR ASSIGNOR:[13] ______________________________________________________

ADDRESS (required):                      __________________________________________________________________

__________________________________________________________________

Should your address be kept confidential from the other party:   Yes   □    No □

TELEPHONE NUMBER:                   HOME: _______________  WORK: ______________  CELL: ______________

Should your phone number be kept confidential from the other party:   Yes   □    No □

SOCIAL SECURITY NUMBER (required): __________________     DATE OF BIRTH: _____________________

EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______                                       (M or F)

EMPLOYER NAME: _______________________________________________________________________

ADDRESS: _______________________________________________________________________________

RESPONDENT’S NAME:                 __________________________________________________________________

ADDRESS (required):                      __________________________________________________________________

__________________________________________________________________

TELEPHONE NUMBER:                   HOME: _______________  WORK: ______________  CELL: ______________

SOCIAL SECURITY NUMBER: _________________________ DATE OF BIRTH: _____________________

EYE COLOR: ____________ HAIR COLOR: ___________ HEIGHT: _________ WEIGHT _______                                       (M or F)

EMPLOYER NAME: _______________________________________________________________________

ADDRESS: _______________________________________________________________________________

Children(s) Names Date of Birth             Social Security Number   (M or F)

List any other names you or the other party may have been previously known by (i.e., maiden name, previous marriage name, etc.)

PETITIONER: _____________________________________________________________________________

RESPONDENT: ___________________________________________________________________________

ARE YOU SCHEDULED IN ANY OTHER COURT OR CASE WITH THE PERSON YOU ARE FILING AGAINST?    □ YES – Court:__________________County:  ________________

                                                                              Docket or index number: __________________________

                                                                              Date of next appearance: __________________________                                                                   NO                              

Dated:

____________________________

Signature of Petitioner

____________________________

Print or type name

____________________________

Signature of Attorney, if any

____________________________

Attorney’s Name (Print or Type)

____________________________

____________________________

____________________________

Attorney’s Address & Telephone Number

ATTORNEY ADVERTISING: Information herein and is not intended to be, legal advice. This sample legal document is provided as part of a free public educational service by Zachary Irtaza Riyaz, Esq., attorney at law in the State of New York (Westhampton – Tel. 516-234-0348), for reference only. IT IS NOT INTENDED TO GIVE LEGAL ADVICE ABOUT A SPECIFIC LEGAL PROBLEM, NOR DOES IT CREATE AN ATTORNEY-CLIENT RELATIONSHIP. Due to the importance of the individual facts of every case, the generalizations I make may not necessarily be applicable to any particular case. Statutes and codes such as Domestic Relations Law (DRL)are frequently amended and may affect the validity of the above legal document and no representation is made that the above sample is going to be enforceable in the future.Changes in the law could at any time make parts of this web site content obsolete. Updated statutes and codes may be available at the New York State Legislature Website. No statute or sample legal document should be relied on without understanding controlling case law which may further interpret it. THIS INFORMATION IS PROVIDED WITH THE UNDERSTANDING THAT IF LEGAL ADVICE IS REQUIRED THE SERVICES OF A COMPETENT ATTORNEY WILL BE CONSULTED.


[1] Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov).

[2]Pursuant to Section 111-g of the Social Services Law, signing this petition is deemed to be an application for child support enforcement services.

[3]Pursuant to Section 433 of the Family Court Act, you may qualify to testify by telephone, audio-visual means or other electronic means if you reside in a county in New York State not contiguous to the Family Court in which the matter will be heard, if you are incarcerated and do not expect to be released within a reasonable period of time after the scheduled date or if you will suffer an undue hardship by appearing in court. The five counties of New York City are treated as one county for purposes of this section.  If you wish to request permission, you must submit Form 4-24/5-16/UIFSA-10, which you may obtain from Family Court or on the internet at http://www.nycourts.gov.

[4] NOTE:  objections may not be filed to an order based upon a support agreement, that is, an order  issued upon consent of the parties.

[5] This paragraph is to be used only if the court’s order deviates from the basic child support obligation, pursuant to F.C.A. Section 413(1)(g).  Delete if inapplicable.

[6] “Default”, as defined in CPLR 5241, means the failure to remit three payments on the date due in the full amount directed in this order, or the accumulation of arrears, including amounts arising from retroactive support, that are equal to or greater than the amount directed to be paid for one month, whichever occurs first.

[7] Inapplicable where support obligor is receiving SSI or social security disability benefits. See FCA §437-a.

[8] Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov).

[9] Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov).

[10]Pursuant to Section 111-g of the Social Services Law, signing this petition is deemed to be an application for child support enforcement services.

[11]Pursuant to Section 111-g of the Social Services Law, where an order of support directs that support payments be made to the support collection unit of a social services district, the petition in such proceeding shall be deemed to be an application for support services.

[12] In IV-D cases where rights have been assigned, give information as to assignor.

[13] In IV-D cases where rights have been assigned, give information as to assignor.

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