F.C.A. §§ 415, 416, 421, 422, 432, 424, 571; S.S.L. §§ 101, 102 C.P.L.R. 5242 [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 Form 4-3a (Support) 6/2012 Docket No. Support under Article 4 of the Family Court Act (Commissioner of Social Services, Assignee on behalf of , Assignor) Petitioner, -againstRespondent. ........................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner is Commissioner of Social Services whose official address is in the County of , State of New York and is authorized to originate this proceeding (as assignee) pursuant to the Social Services Law and the Family Court Act of the State of New York. 2. The assignor is authorized to originate a support proceeding but has assigned her/his right to do so to the Commissioner of Social Services pursuant to the Social Services Law of the State of New York. In the event the assignment ends the assignor may pursue support and may seek an order of support. 3. (Upon information and belief) (Assignor) and Respondent were married at , .) 4. Respondent is chargeable with the support of the following: Date of Birth PETITION (Commissioner) on Name Spouse: Child(ren) 5. (Upon information and belief) Respondent, on or about , , and since that date, has failed to provide fair and reasonable support for the above-named dependent(s) according to Respondent's means and earning capacity. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-3a page 2 [Check boxes if applicable; delete paragraphs 5 and/or 6 if inapplicable]: 6.Respondent is unlikely to make payments in accordance with the order of support requested, because of G past lack of financial responsibility G credit references G credit history G other [specify]: 7. Respondent has the following source of income: Gemployer Gincome payor, as defined in CPLR Sec.5241(a), whose name and address are [specify]: 8. 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, Petitioner requests an order for support1 directing Respondent to pay fair and reasonable support payable to the Commissioner of Social Services or, in the event that the assignment ends, payable to the ex-assignor, requiring Respondent to 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 Pursuant to Section 111-g of the Social Services Law, where an order of support directs that support payments be made to the support collection unit of a social services district, the petition in such proceeding shall be deemed to be an application for support services. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 4-3a page 3 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 American LegalNet, Inc. www.FormsWorkFlow.com Form 4-3a page 4 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