Form 4-1 Page 1 F.C.A. §§ 413, 416, 424, 425; SSL§ 111-g [NOTE: Personal Information Form 4-5/5-1-d, containing social security numbers of parties and dependents, must be filed with this Petition] FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................. In the Matter of Petition for an Order Upon an Agreement of Support, between (Commissioner of Social Services, Assignee , Assignor) on behalf of Petitioner, -againstRespondent ............................................................................. The Petitioner respectfully alleges that: 1. a. Petitioner (resides at) (official address is)[specify]:1 b. Respondent resides at2 2. Petitioner and Respondent have entered into a written agreement for the support of Age Date of Birth Name Spouse: Child(ren): PETITION (For an Order Upon Support Agreement) (Support­Petition for an Order Upon Support Agreement) 10/2016 Docket No. in the amount of [specify]: . A true copy of said agreement for support is attached hereto and made a part hereof, which agreement contains a provision stating that the parties have been advised of the provisions of section 413, subdivision 1, of the Family Court Act. 3. Petitioner and Respondent have consented to the entry of an order by this Court upon the agreement for support. 1 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). 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 4-1 Page 2 4. [Applicable to individual petitioners; if agency, skip to ¶ 5; check a box only if applicable]: I am hereby applying for child support services from the Support Collection Unit (the IV-D program pursuant to Title 6-A of the Social Services Law) through the filing of this Petition, unless: I have already applied for child support services from the Support Collection Unit (the IV-D program pursuant to Title 6-A of the Social Services Law) I do not need to apply now because I have continued to receive child support services after the public assistance or care case, or foster care case, for my family has closed. I do not wish to apply for child support services. I am not eligible to apply for child support services because I am petitioning for spousal support only. 5. No previous application has been made to any judge or court, including a Native American tribunal, or is presently pending before any judge or court, for the relief requested in this petition (except WHEREFORE, the Petitioner requests that the agreement of support annexed to this petition be approved and confirmed pursuant to Article 4 of the Family Court Act and that an order of support upon the agreement be entered by this Court and that Respondent be required to exercise the option of additional coverage for health insurance in favor of (his)(her) spouse and above-named child(ren). NOTE: (1) A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) 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 SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT. (2) A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVING FAMILY ASSISTANCE SHALL HAVE A 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 BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY. ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS, AS American LegalNet, Inc. www.FormsWorkFlow.com Form 4.1 Page 3 REQUIRED BY SECTION FOUR HUNDRED FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, 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 ADJUSTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER. _______________________________ Petitioner _______________________________ Print or type name _______________________________ Signature of Attorney, if any _______________________________ Attorney's Name (Print or Type) _______________________________ _______________________________ Attorney's Address and Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com