F.C.A. §§ 433, 453, 454, ART.5-B; C.P.L.R § 5242 Form 4-12a-1 (Violation of Support Order) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of a Proceeding for Support under Article of the Family Court Act (Commissioner of Social Services, Assignee on behalf of , Assignor) Petitioner, -againstRespondent. NOTICE: YOUR FAILURE TO APPEAR IN COURT MAY RESULT IN YOUR IMMEDIATE ARREST. YOUR FAILURE TO APPEAR MAY RESULT IN SUSPENSION OF YOUR DRIVER'S LICENSE, STATE-ISSUED PROFESSIONAL, OCCUPATIONAL AND BUSINESS LICENSES; AND RECREATIONAL AND SPORTING LICENSES AND PERMITS. YOU HAVE THE RIGHT TO BE REPRESENTED BY A LAWYER. IF YOU CANNOT AFFORD A PRIVATE LAWYER, YOU HAVE THE RIGHT TO ASK THE COURT TO ASSIGN A LAWYER. IF, AFTER HEARING, THE JUDGE FINDS THAT YOU WILLFULLY FAILED TO OBEY THE ORDER, YOU MAY BE IMPRISONED FOR A TERM NOT TO EXCEED SIX MONTHS FOR CONTEMPT OF COURT. IN THE NAME OF THE PEOPLE OF THE STATE OF NEW YORK TO THE ABOVENAMED RESPONDENT: who resides or is found at A petition having been filed alleging that you have failed to obey the support order dated , made by this Court under Article of the Family Court Act, a copy of the petition being annexed hereto; YOU ARE HEREBY SUMMONED to appear before this Court at , SUMMONS (Violation of Support Order) Docket No. New York on , , at o'clock in the noon of that day to answer the petition and show cause why you should not be dealt with in accordance with Section 454 of the Family Court Act and Section 5242 of the Civil Practice Law and Rules. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-12-a-1 page 2 Dated: , . BY ORDER OF THE COURT Clerk of the Court NOTICE: 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 www.nycourts.gov. NOTICE: Family Court Act §154(c) provides that petitions brought pursuant to Articles 4, 5, 6, 8 and 10 of the Family Court Act, 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. If no other grounds for obtaining personal jurisdiction over the Respondent exist aside from the application of this provision, 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. 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. American LegalNet, Inc. www.FormsWorkFlow.com