F.C.A. §§ 413, 440, 442-447, 449, 451, 461, 466, 467 Form 4-11a (Support- Order Extending, Modifying or Terminating Order of Support Made by Family Court or Another Court) 9/2007 At a term of the Family Court of the State of New York, held in and for the County of , at , New York on , . P R E S E N T: Hon. Judge/Support Magistrate ................................................................................ In the Matter of a Proceeding for Support under Article 4 of the Family (Commissioner of Social Services, Assignee, on behalf of , Assignor) Petitioner, S.S. # Docket No. ORDER ON PETITION TO G EXTEND G MODIFY G TERMINATE AN ORDER OF SUPPORT MADE BY G FAMILY COURT G ANOTHER COURT -againstRespondent S.S.# ................................................................................ NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN INCARCERATION FOR CRIMINAL NON-SUPPORT OR CONTEMPT. YOUR FAILURE TO OBEY THIS ORDER MAY RESULT IN 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 WAS ENTERED BY A JUDGE, THE ORDER MAY BE APPEALED PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT. THAT SECTION PROVIDES THAT AN APPEAL FROM THAT ORDER MUST BE TAKEN WITHIN 30 DAYS AFTER RECEIPT OF THE ORDER BY THE APPELLANT IN COURT, 30 DAYS AFTER SERVICE BY A PARTY OR THE LAW GUARDIAN UPON THE APPELLANT, OR 35 DAYS American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 2 FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF THE COURT, WHICHEVER IS EARLIEST. IF THIS ORDER WAS 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. The petition having been filed in this Court seeking to Q terminate Q extend Q modify a Q judgment Qorder, dated , , granting support made by the Q Supreme Court of the State of New York, County, entitled Index No. Q Family Court of County Q Other court: ; and [Check applicable box(es)]: Q It appearing that under the terms of the Q judgment Q order the Q Supreme Court Q Other [specify]: has not retained exclusive jurisdiction to modify the Q judgment Q order; and Q It appearing that the outside the State of New York; and Court is a court of competent jurisdiction The matter having duly come on to be heard before this Court, and it appearing that there Q has Q has not been a change of circumstances since the entry of the Qjudgment Qorder, which makes the modification of the Qjudgment Qorder necessary and proper; NOW, after examination and inquiry into the facts and circumstances of the case, and after hearing the proofs and testimony, the Court finds that; The basic child support obligation for support of the following child(ren) is $____________ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly: NAME DATE OF BIRTH SOCIAL SECURITY # AMOUNT The mother is the Qcustodial Q non-custodial parent, whose pro rata share of the basic child support obligation is $_______________; The father is the Qcustodial Qnon-custodial parent, whose pro rata share of the basic child obligation is $ ___________ Q weekly, Q every two weeks, Q monthly, Q twice per month, American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 3 Q quarterly; And the Court finds further that: G The non-custodial parent's pro rata share of the basic child support obligation is neither unjust nor inappropriate; 1 OR G 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: G unjust G inappropriate;2 [Applicable in cases in which the parties stipulated to an order of child support]: Q And the Court finds that the parties have voluntarily stipulated to child support for the child(ren)[names] __________________________________________ payable by ________________________ in the amount of $____________ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly. Q This stipulation has been entered into the record and recites, in compliance with Family Court Act § 413(1)(h), that: a. The parties have been advised of the provisions of Family Court Act §413(1); 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 Social Services Law § 111-i; 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 $__________ G weekly G every two weeks G monthly Gtwice per month G 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]: ; G The Court approves the parties' agreement to deviate from the basic child support obligation for the following reasons: [specify; see Family Court Act Section 413(1)(f)]: ; The name, address and telephone number of Q Respondent’s Q (modification only): Petitioner’s 1 current employer(s), are: This paragraph is to be used if the basic child support obligation is applied without deviation. 2 This paragraph is to be used only if the court's order deviates from the basic child support obligation, pursuant to F.C.A.§ 413(1)(g). American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 4 NAME ADDRESS TELEPHONE NOW, therefore, it is hereby G ORDERED that the petition for modification is DENIED. OR G ORDERED that the Q judgment Qorder, dated , , is terminated; G ORDERED that the Qjudgment Q order dated further order of this Court; , , is continued until G ORDERED that the Q judgment Qorder, dated following respects [specify]: , , is modified in the G AND the defaulting party having Q shown Qfailed to show good cause for failure to make an application for relief from the judgment or order directing payment prior to the accrual of the arrears, it is G ORDERED that arrears in the amount of $ are Q annulled Qreduced to $ Q fixed at the full amount of $ ; and it is further G ORDERED that judgment be entered in favor of the Petitioner against the Respondent in the amount of $ , “ plus interest [CPLR 5004] from , , in the amount of $ , “ plus costs and disbursements in the amount of $ , for a total sum of $ ; and it is further G ORDERED and ADJUDGED that the above-named Q Respondent Q Petitioner is responsible for the support so ordered from the date of the filing of the petition to the date of this Order Q less the amount of $ already paid, and that the Q Respondent Q Petitioner shall pay the sum of $ as follows: $ immediately, $ Q weekly, Q every two weeks, Q twice per monthly, Q quarterly, to [check applicable box]: 9 Petitioner by cash, check or money order 9 Respondent by cash, check or money order 9 Non-IV-D cases: N.Y.S. Office of Temporary and Disability Assistance made by check or money order payable to and mailed to P. O. Box 15365, Albany, NY 12260. The county name and account number for the matter must be included with the payment for identification purposes. 9 IV-D cases: Support Collection Unit made by check or money order payable to and mailed to N.Y.S. Child Support Processing Center, P. O. Box 15363, Albany, NY 12212-5376. The county name and account number for the matter must be included with the payment for identification purposes ; and it is further [Non-IV-D cases only]: G ORDERED that, pursuant to Family Court Act Section 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 G ORDERED that, for the following reason(s) American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 5 constituting good cause pursuant to Section 440(1)(b) of the Family Court Act, the G IV-D cases: Support Collection Unit G 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]: G 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 or premium, or extent and availability of existing or new benefits; And the Court having determined that [check applicable box]: G The child(ren) are currently covered by the following health insurance plan [specify]: which is maintained by [specify party]: G Health insurance coverage would be 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, any medical dental, optical, prescription drug and health care services or other health care benefits]: G Health insurance coverage is available to both of the parents as follows: Name Health Insurance Plan Premium or Contribution Benefits G 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, it is hereby IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]: G 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; G enroll the following eligible dependent(s) [specify]: under the following health insurance plan [specify]: 6 “Default”, as defined in CPLR 5241, means the failure to make 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. American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 6 immediately and without regard to seasonal enrollment restrictions and maintain such coverage as long as it remains available in accordance with [IV-D cases]: G the Medical Execution, which shall be issued immediately by the Support Collection Unit, pursuant to CPLR 5241 G the Medical Execution issued by this Court [Non-IV-D cases]: G 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 above 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 legallyresponsible 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 G This Court having found that neither of the parties have health insurance coverage available to cover the child(ren), it is hereby 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, it is hereby. And the Court further finds that: The mother is the Q custodial Q 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 Q custodial Q 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]: G 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; G 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 ORDERED that the legally responsible relative immediately notify the [check applicable box]: American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 7 G other party (non-IV-D cases) G Support Collection Unit (IV-D cases) of any change in health insurance benefits, including any termination of benefits, 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 payments 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)]: G this order G the medical execution G 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) Q was Q 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 Q his Q her pro rata share of future reasonable health expenses of the child(ren) not covered by insurance by [check applicable box]: G direct payments to the health care provider G other [specify]: ; and it is further ORDERED that, if health insurance benefits for the above-named child(ren) are 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): G ORDERED that herein, pay the sum of $ care expenses, to be paid as follows: , the non-custodial parent as Q his Q her proportionate share of reasonable child ; and it is further G ORDERED that , the non-custodial parent herein, pay the sum of $ as educational expenses by G direct payment to the educational provider G other [specify]: ; and it is further G ORDERED that [specify party or parties; check applicable box(es): G purchase and maintain G life and/or G accident insurance policy in the amount of [specify]: (and/or) G maintain the following existing G life and/or G accident insurance policy in the amount of [specify]: (and/or) G assign the following as G beneficiary G beneficiaries [specify]: American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 8 to the following existing G life and/or G 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 [IV-D Cases}: G 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 [REQUIRED] IT IS FURTHER ORDERED that a copy of this order be provided promptly by [check applicable box]:G Support Collection Unit ((IV-D cases: ) G 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: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 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 American LegalNet, Inc. www.FormsWorkflow.com Form 4-11a page 9 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 ON OR AFTER THE EFFECTIVE DATE OF THE ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER. American LegalNet, Inc. www.FormsWorkflow.com