F.C.A. Article 4, S.S.L.§ 111 -k ; Public Health Law§ 4135-b [NOTE: Personal Information Form 4-5/5-1-d, containing social security numbers of parties and dependents, must be filed with this Petition] Form 4-18 (Petition for Support After Acknowledgment Of Paternity­Individual) 10/2016 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................ IN THE MATER OF A PROCEEDING FOR SUPPORT UNDER ARTICLE 4 OF THE FAMILY COURT ACT Petitioner, -against- DOCKET NO. PETITION FOR SUPPORT AFTER ACKNOWLEDGMENT OF PATERNITY (INDIVIDUAL) Respondent. ............................................................................................. TO THE FAMILY COURT: 1. a. I reside at [specify]:1 b. The Respondent resides at [specify]:2 2. a. [Applicable when Mother is Petitioner]: I am authorized to originate this proceeding because on [specify date]: I executed an acknowledgment of paternity pursuant to Social Services Law 111-k and Public Health Law § 4135-b acknowledging that I am the mother of [specify child]: who was born out of wedlock on [specify birth date]: in [specify city and state of birth]: The acknowledgment stated that Respondent [specify]: is the only possible father of the child. b. [Applicable when Father is Petitioner]: I am authorized to originate this proceeding because on [specify date]: I executed an acknowledgment of paternity pursuant to Social Services Law 111-k and Public Health Law § 4135-b acknowledging that I am the father of [specify child]: who was born out of wedlock on_[specify birth date]: in [specify city and state of birth]: 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. The child or children's name(s) and date(s) of birth are as follows: Date of Birth Name 4. The Respondent is chargeable with the support of the above-named child in that she he duly executed an acknowledgment of paternity pursuant to SSL§ 111-K and P.H.L.§ 4135-b on [specify date]: acknowledging that [check applicable box]: she is the mother he is the biological father of the child. 5. The acknowledgment has has not been filed with the appropriate registrar of birth records and a copy is is not attached to this petition and made a part of it. [NOTE: if acknowledgment is attached, Petitioner MUST black out or redact social security numbers]. 6. (Upon information and belief) Respondent, on or about [specify date]: and after that date, has failed to provide fair and reasonable support for the child according to Respondent's means and earning capacity. [Check boxes if applicable; delete paragraphs 7 and/or 8 if inapplicable]: 7. Respondent's past financial responsibility credit references credit history and other [specify]: make it unlikely that Respondent will make payments in accordance with the order of support requested in this petition. 8. Respondent has an employer income payor, as defined in CPLR Sec.5241(a), whose name and address are [specify]: , as a source of income. 9. [Applicable to individual petitioners; if agency, skip to ¶ 6: 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 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 WHEREFORE, Petitioner requests an order of support directing Respondent to pay fair and reasonable support, requiring that Respondent exercise the option of additional coverage for health insurance in favor of his her above-named child(ren), and for such other and further relief as the law provides. 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 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. ____________