Page 1 S.S.L§§ 111-g; F.C.A; 416, 421, 422, 423; CPLR 5242 [NOTE: Personal Information Form 4-5/5-1-d, 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 Petitioner, -againstRespondent. ................................................................................ TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. a. I reside at [specify]:1 b. Respondent resides at [specify]:2 2. I am authorized to originate this proceeding because [check applicable box(es)]: Respondent and I were married at on Respondent and I have the child(ren) named below in common Other [specify Petitioner's relationship to child(ren)]: 3. Respondent is chargeable with the support of the following spouse and dependent(s): NAME SPOUSE: CHILD(REN): DATE OF BIRTH SUPPORT PETITION (Individual) Form 4-3 (Support­Petition­ Individual) 10/2016 Docket No. 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). American LegalNet, Inc. www.FormsWorkFlow.com 1 Page 2 4. [Check applicable box(es); if children have different fathers, include separate paragraphs]: The father of the of the above-named child(ren) is [specify]: . The father was married to the child(ren)'s mother at the time of the conception or birth. An order of filiation was made on [specify date and court and attach true copy]: An acknowledgment of paternity was signed on [specify date]: by [specify who signed and attach a true copy]: The father is deceased. The father of the below-named child(ren) has not been legally established. A paternity agreement or compromise was approved by the Family Court of [specify county]: County on , , concerning [name parties to agreement or compromise and child(ren)]: . A true copy of the agreement or compromise is attached. 5. [Applicable to cases in which mother is not a party]: The name and address of the mother is [indicate if deceased or if address ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]: 6. [Check applicable box(es); if not applicable, SKIP to ¶7]: Respondent has an employer income payor, as defined in Civil Practice Law and Rules 5241(a), whose address is [specify]: , as a source of income. 7. 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 [check a box only if applicable]: 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. 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, I am requesting that this Court issue an order of support directing Respondent to pay fair and reasonable support, that Respondent be required to exercise the option of additional coverage for health insurance in favor of (his) (her) spouse and 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 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 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 TWENTYFOUR 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. Dated: ____________________________ 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