F.C.A. §4511 Form 4-11b (Affidavit in Support of of Modification of Support) 8/2010 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 Petitioner, -againstAFFIDAVIT IN SUPPORT OF MODIFICATION OF SUPPORT Family File No.: Docket No. Respondent. STATE OF NEW YORK COUNTY OF ) )ss. ) ________________________________, being duly sworn, deposes and states the following: 1. I am submitting this affidavit in support of the application for modification of a support order made in the Family Court Supreme Court [specify county]: , 2 dated ___________________. I reside at [specify full address]: 2. The support order sought to be modified is for the support of child(ren) spouse spouse and child(ren). 3 Upon information and belief, I am seeking modification because [check applicable box]: There have been the following substantial changes in circumstances since the support order was made: Increased needs of the children [specify]: 1. Family Court Act §451 provides that "no hearing shall be required unless such application [to modify] shall be supported by affidavit and other evidentiary material sufficient to establish a prima facie case for the relief requested." 2. 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). American LegalNet, Inc. www.FormsWorkFlow.com Form 4-11b Needs of the children that are not being met [specify]: Page 2 Change in the ability of the payor to pay support [specify]: Other [specify]:3 Unless the parties have specifically agreed otherwise in a validly executed agreement or stipulation, three years have passed since the order was entered, last modified or adjusted.4 Unless the parties have specifically agreed otherwise in a validly executed agreement or stipulation, 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 [state basis]:5 Dated: Signature of Petitioner Sworn to before me this ____ day of _______________________________ (Deputy) (Chief) Clerk of Court Notary Public/Commissioner of Deeds Signature of Attorney, if any Attorney's Name (Print or Type) Print or type name Attorney's Address and Telephone Number 3 If incarceration is the basis for alleging substantial change in circumstances, so state and indicate whether or not the incarceration resulted from a charge and/or conviction for nonpayment of child support or an offense against the custodial parent or child who is the subject of the child support order. See Family Court Act §451(2)(a); Domestic Relations Law §236B(9)(b)(2)(i). 4 This ground only applies to original or modified support orders entered on or after October 13, 2010. This ground only applies to original or modified support orders entered on or after October 13, 2010. American LegalNet, Inc. www.FormsWorkFlow.com 5