F.C.A.§§ 413, 416, 433, 434, 439, 439-a, 440; D.R.L.§ 240 Form 4-6a (Referral to Support Magistrate and Temporary Order of Support) 5/2015 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 ..................................................................... In the Matter of a Proceeding under Article of the Family Court Act Docket No. REFERRAL TO SUPPORT MAGISTRATE and TEMPORARY ORDER OF SUPPORT1 Petitioner, S.S.#: xxxx-xx-against- Respondent S.S.#: xxxx-xx...................................................................... NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS FOR CONTEMPT OF COURT OR PROSECUTION FOR CRIMINAL NON-SUPPORT. YOUR FAILURE TO OBEY THIS ORDER MAY RESULT IN 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. A petition in this proceeding, dated: , , having been filed in this Court, and it appearing that the Court has jurisdiction over the parties and that there is an issue of support; and Respondent having appeared before this Court to answer the petition and to show why an order of Support and other relief requested in the petition should not be granted; and Respondent, after having been advised of the right to counsel, having Q denied Q admitted the allegations of the petition; The name, address and telephone number of Respondent's current employer(s) are: ADDRESS TELEPHONE NAME 1 For use where original petition is not filed pursuant to Article 4. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-6a Page 2 NOW, after examination and inquiry into the facts and circumstances of the case (and after hearing the proof and testimony offered in relation thereto), it is ORDERED and that the above-named Respondent, upon notice of this order, pay or cause to be paid to [specify]: G Petitioner G Support Collection Unit at , the sum of $ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly, such payments to commence on , , allocated as follows: for and toward the support of , spouse, the sum of $ , Q weekly, Qevery two weeks, Qmonthly, Qtwice per month, Q quarterly and for and toward the support of the child(ren), the sum of $ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly; Name Spouse: Child(ren): Date of Birth Last 4 Digits of Soc. Sec.# Amount Total: G ORDERED that, pursuant to Domestic Relations Law §236B(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 §236B(9) or 248; and it is further G 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 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 [IV-D cases only]: G ORDERED that the Respondent, custodial parent and any other individual parties immediately notify the Support Collection Unit of any changes in the following information: residential and mailing addresses, social security number, telephone number, driver's license number; and name, address and telephone numbers of the parties' employers and any change in health insurance benefits, including any termination of benefits, change in the health insurance benefit carrier or premium, or extent and availability of existing or new benefits; and it is further [Check box if applicable]: G ORDERED that, for the following reason(s)[specify]: American LegalNet, Inc. www.FormsWorkFlow.com Form 4-6a Page 3 constituting good cause pursuant to Section 440(1)(b) of the Family Court Act, the G IV-D cases: Support Collection Unit G Non-IV-D cases: Court shall NOT issue an immediate income execution; however, in the event of default,6 this order shall be enforceable pursuant to section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; and it is further ORDERED that this order shall be enforceable pursuant to Section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; And the Court having determined that [check applicable box]: G The child(ren) are currently covered by the following health insurance plan [specify]: which is maintained by [specify party]: G Health insurance coverage is available to one of the parents or a legally-responsible relative [specify name]: under the following health insurance plan [specify, if known]: which provides the following health insurance benefits [specify extent and type of benefits, if known, including any medical, dental, optical, prescription drug and health care services or other health-related benefits]: G Health insurance coverage is available to both of the parents as follows: Name Health Insurance Plan Premium or Contribution Benefits G No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) may be eligible for health insurance benefits under the New York "Child Health Plus" program or New York State Medical Assistance Program, or the publicly funded health insurance program in the State where the custodial parent resides, G No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) are currently enrolled in the New York State Medical Assistance Program. IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]: G continue to maintain health insurance coverage for the following eligible dependent(s) [specify]: under the above-named existing plan for as long as it remains available; G enroll the following eligible dependent(s) [specify]: under the following health insurance plan [specify