F.C.A.§§ 413, 416, 439(e) Form 4-SM.-3 (Support ­ Findings of Fact) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................. In the Matter of a Proceeding for Support (Commissioner of Social Services, Assignor, on behalf of , Assignee) Docket No. FINDINGS OF FACT Petitioner -againstRespondent. ............................................................................................. , being the Support Magistrate before whom the issues of support in the aboveentitled proceeding were assigned for determination, makes the following findings of fact: [check applicable boxes]: 1. Petitioner and Respondent were: Q married on [specify date]: Q are still husband and wife Q never married to each other. 2. , and Q were divorced on [specify date]: Q The following children were born of this marriage [specify]: Q There are no children born of this marriage. 3. Q a. Respondent is liable for the support of the following child(ren): [specify]: Child's Date of Birth Name of Child b. The basis of, or reason for, Respondent's liability is [specify]: Q Respondent is not liable for the support of the children. 4. a. The following child(ren) [state name(s)]: reside with Petitioner. b. The following child(ren) [state name(s)]: American LegalNet, Inc. www.FormsWorkFlow.com reside with Respondent. 5. a. Petitioner: Q filed a net worth statement or financial disclosure affidavit. Q did not file a net worth statement or financial disclosure affidavit and Q did Q did not have good cause for not filing. b. Respondent: Q filed a net worth statement or financial disclosure affidavit. Q did not file a net worth statement or financial disclosure affidavit and Q did Q did not have good cause for not filing. 6. The basic child support obligation for support of the following child(ren) [specify name(s)]: ________________________________________________________________________________ is $ __________ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. 7. The mother is the Q custodial Q non-custodial parent, whose pro rata share of the basic child support obligation is $ __________ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. 8. The father is the Q custodial Q non-custodial parent, whose pro rata share of the basic child support obligation is $ __________ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. 9. . Q Petitioner has available health insurance coverage under [specify plan]: This plan: Q covers the following children [specify]: with the following contribution or premium paid by Petitioner $ ______ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. Q can be extended to cover the following children [specify]: with the following contribution or premium paid by Petitioner $ ______ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. This plan contains the following benefits: Q medical Q dental Q prescription drugs Q optical Q other health care benefits [specify]: ________________________ Q Respondent has available health insurance coverage under [specify plan]: This plan: Q covers the following children [specify]: with the following contribution or premium paid by Petitioner $ ______ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. American LegalNet, Inc. www.FormsWorkFlow.com Q can be extended to cover the following children [specify]: with the following contribution or premium paid by Petitioner $ ______ Q weekly Q every two weeks Q monthly Q twice per month Q quarterly. This plan contains the following benefits: Q medical Q dental Q prescription drugs Q optical Q other health care benefits [specify]: ________________________ Q Neither Petitioner nor Respondent have available health insurance coverage. 10. a. Health insurance coverage for the children is ordered as follows: Q Petitioner is directed to continue the health insurance coverage for the following child(ren) [specify]: with costs to be allocated between the parties as follows [specify]: Q Petitioner is directed to enroll the following child(ren) [specify]: in the above-named health insurance plan, effective [specify date]: with costs to be allocated between the parties as follows [specify]: child(ren) [specify]: follows [specify]: , Q Respondent is directed to continue the health insurance coverage for the following with costs to be allocated between the parties as in , with Q Respondent is directed to enroll the following child(ren) [specify]: the above-named health insurance plan, effective [specify date]: costs to be allocated between the parties as follows [specify]: shall immediately apply to enroll the child(ren) in the NYS "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. If the child(ren) is/are accepted into the "Child Health Plus Program," the cost of the premiums or family contribution shall be allocated between the parties as follows: b. The allocation between the parties of costs of medical premiums or contributions in paragraph a : Q The custodial parent [specify]: Q is prorated in the same proportion as each parent's income is to the combined parental income. Q is not prorated in the same proportion as each parent's income is to the combined parental income, because that would be unjust or inappropriate for the following reason(s) [specify]: OR c. Q [Where the child(ren) are recipients of coverage under the managed care coverage under the New York State Medical Assistance Program] i. The monthly premium for managed care coverage under the New York State Medical Assistance Program is $________. American LegalNet, Inc. www.FormsWorkFlow.com ii. The monthly amount that would be required as a family contribution under the state's child health insurance plan pursuant to title one-a of article twenty-five of the public health law (Child Health Plus) for the child(ren) if they were in a two-parent household with income equal to the combined income of the non-custodial and custodial parents is $________. Five percent (5%) of the non-custodial parent's gross income is $________. The non-custodial parent's obligation for managed care coverage under the New York State Medical Assistance Program is $________. iii. iv. v. Q The obligation for managed care coverage under the New York State Medical Assistance Program would r