Page 1 F.C.A. §§ 440, 442-447, 449, 451, 461 466, 467, S.S.L. § 111-g [NOTE: Personal Information Form 4-5/5-1d, 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 a Proceeding for Support Under Article 4 of the Family Court Act Form 4-11 (Support-Petition for Modification) 10/2016 Docket No. (Commissioner of Social Services, Assignee, , Assignor) on behalf of Petitioner, (Assignor) -againstRespondent. ....................................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully shows that: PETITION FOR MODIFICATION OF AN ORDER OF SUPPORT MADE BY FAMILY COURT ANOTHER COURT 1. a. I am [check box]: an individual and am related to the child(ren) as follows [specify]: and I reside at [specify]:1 assignee agency, which has its place of business at [specify]: b. Respondent resides at [specify]:2 . 2. a. I was the petitioner respondent in an action instituted in the Supreme Court of the State of New York, [specify county]: County Other Court [specify other court]: Court of b. The action was named [specify]: , Index/Docket No. [specify]: Respondent was petitioner respondent in the action. 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). 1 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 3. a. A judgment order, dated Respondent Petitioner to [specify terms]: , was entered in the action directing the . A true copy of the judgment order is attached and made a part of this Petition. b. An order of support dated Petitioner to [specify terms]: , was entered directing the Respondent . A true copy of the judgment order is attached and made a part of this Petition. 4. The names, addresses and dates of birth of all children affected by this order are: CHILD'S NAME ADDRESS3 DATE OF BIRTH 5. a. Under the terms of the judgment order, the Supreme Court Other Court [specify]: has not retained exclusive jurisdiction to modify the judgment order. b. [Check if applicable]: The other Court is a court of competent jurisdiction outside the State of New York. 6. (Upon information and belief) I have standing to seek a modification of child support because, since the entry of the judgment order, [check applicable box]: there has been a substantial change of circumstances in that [specify]:4 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). 4 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). 3 American LegalNet, Inc. www.FormsWorkFlow.com Page 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. [NOTE: This ground only applies to original or modified support orders entered on or after October 13, 2010]. 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. [NOTE: This ground only applies to original or modified support orders entered on or after October 13, 2010]. The basis for this allegation is as follows [specify]: 7. The judgment order should be modified as follows [specify]: . 8. [Delete if inapplicable]: I did not make an application earlier for relief from the judgment order directing payment prior to the accrual of arrears because (s)[specify reason(s)]: 9. [Applicable to individual petitioners; if agency, skip to ¶10]: 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. 10. 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, I respectfully request that the judgment order of the Supreme Court Other Court [specify]: , dated , be modified as set forth above and for such other relief as the Court may deem just and proper. NOTE: (1) 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 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 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) RECEIVIN