F.C.A.§ 413, Art.5-B Form 4- SM-1 (Stipulation for Child Support) 4/2011 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .......................................................................................... (Commissioner of Social Services, Assignee, on behalf of , Assignor) Petitioner, S.S.#: xxxx-xx-againstDocket No. Respondent. S.S.#: xxxx-xx......................................................................................... 1. The parties to this stipulation are: , the mother, and , the father of the following child(ren) [List names, dates of birth, of each child]: NAME DATE OF BIRTH STIPULATION FOR CHILD SUPPORT 2. A petition seeking support for the above-named child(ren) was filed by, , Petitioner, against , Respondent, in the Family Court, County, on , , 3. As otherwise indicated in the court record, the parties appeared today Gwith Gwithout counsel before Support Magistrate and indicated that they wish voluntarily to make a stipulation for the support of the above-named child(ren) as permitted by Section 413(l)(h) of the Family Court Act. Accordingly, the parties stipulate as follows: a. They are aware of the provisions of the Child Support Standards Act, Section 413(l) and 416 of the Family Court Act, and that the basic child support obligation as defined Section 413(1) is the presumptively correct amount of child support. b. They are aware of the provisions of Section 416 of the Family Court Act regarding accident, life and health insurance, including the requirement that a party provide health American LegalNet, Inc. www.FormsWorkFlow.com Form 4-SM-1 Page 2 insurance, if available. The parties voluntarily agree to waive the issuance by the Court of a separate order with respect to provision of [check applicable box(es)]: Gaccident Glife insurance. The parties voluntarily agree to the issuance of a G IV-D case: medical execution GNon-IV-D case: Qualified Medical Child Support Order Gwaive the issuance of a medical execution or order. c. The unrepresented party, if any, has received a copy of the child support standards chart promulgated by the Commissioner of the New York State Office of Temporary and Disability Assistance pursuant to Section 111-i of the Social Services Law. d. The amount of the basic child support obligation for the child(ren) in this case is $ G weekly G every two weeks G monthly Gtwice per month G quarterly. e. The parties agree that the amount of child support to be ordered in this proceeding is $ , per to be paid by to . as follows: Name Date of Birth Amount Total: f. The parties' reason(s) for agreeing to child support in an amount different from the basic child support obligation (is) (are): [specify; see Family Court Act § 413(l)(f)]: ; g. The Court approves the parties' agreement to deviate from the basic child support obligation for the following reasons: [see Family Court Act Section 413(1)(f)]: h. The name, address and telephone number of Respondent's current employer(s), are: NAME ADDRESS TELEPHONE i. The parties agree that the Respondent is chargeable with the support of the following person(s) and is possessed of sufficient means and able to earn such means to provide the payment of the sum $ G weekly G every two weeks G monthly Gtwice per month G quarterly, such payments to commence on , , allocated as American LegalNet, Inc. www.FormsWorkFlow.com Form 4-SM-1 Page 3 follows for and toward the support of Respondent's spouse and children as follows: Name Date of Birth Amount Per Time Period 1 spouse: child(ren): Total: j. The parties agree that payments for the support of Respondent's spouse shall terminate upon the death of the spouse; and it is further k. The parties agree that the Respondent is responsible for the support so ordered from the date of the filing of the petition to the date of this Order (less the amount of $ already paid) and that the Respondent pay the sum of $ as follows: $ immediately, and $ G weekly G every two weeks G monthly Gtwice per month G quarterly; and it is further l. The parties agree that commencing on _______________________ the Respondent, upon notice of this Order, shall pay or cause the above amount(s) to be paid to 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 P. O. Box 15365, Albany, NY 12212-5365. The county name and account number 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 account number for the matter must be included with the payment for identification purposes; and it is further m. [IV-D cases only]: The parties agree that the Respondent, custodial parent and any other individual parties shall 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 n. The parties agree that [specify]: shall pay to [specify]: , the attorney for the other party, the sum of $ for counsel fees in this proceeding, which payment may be made in installments of $ G weekly G every two weeks G monthly Gtwice per month G quarterly , commencing on [specify]: , 1 Specify whether support amount is weekly, every two weeks, monthly, twice per month or quarterly. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-SM-1 Page 4 , until the entire sum is paid; o. The parties agree 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 care benefits]: G Health insurance coverage is available to both of the parents as follows: Name Health Insurance