F.C.A. §§ 413, 416, 424, 425, 439, 439(a), 440, 449; D.R.L. § 240 Form 4-2 (Order on Support Agreement) 12/2012 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 -againstRespondent. 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. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-2 page 2 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.1 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 Q with counsel Q without counsel and Respondent having appeared Q with counsel Qwithout counsel; and And the Court finds further that [check applicable box]: G The non-custodial parent's pro rata share of the basic child support obligation is neither unjust nor inappropriate; 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 for the following reasons [specify]: 2 And the Court finds further that the parties have voluntarily stipulated to child support for the following child(ren)[specify]: payable by [specify]: G weekly G every two to [specify]: in the amount of $ weeks G monthly Gtwice per month G 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 $__________ G weekly G every two NOTE: objections may not be filed to an order based upon a support agreement, that is, an order issued upon consent of the parties. 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. American LegalNet, Inc. www.FormsWorkFlow.com 1 2 Form 4-2 page 3 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]: ; 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: TELEPHONE ADDRESS NAME 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 Q weekly, Q every two weeks, Qmonthly, Qtwice per month, and Q quarterly as follows: Name Spouse: Date of Birth Last 4 Digits of Soc. Sec. # Amount 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 Q weekly, Q every two weeks, Q monthly, Q twice follows: $ immediately, $ per month, Q 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]: G Petitioner by cash, check or money order G Non-IV-D cases: Payable to the Petitioner by check or money order and mailed to the NYS Child American LegalNet, Inc. www.FormsWorkFlow.com Form 4-2 page 4 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. G 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