F.C.A. §§ 413, 416, 433, 434, 435, 439, 439-a, 440; D.R.L.§ 240 Form 4-6 (Temporary Order of Support and Referral to Support Magistrate) 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/Support Magistrate ....................................................................................... In the Matter of a Proceeding for Support Docket No. under Article 4 of the Family Court Act TEMPORARY ORDER OF (Commissioner of Social Services, Assignee, SUPPORT (and REFERRAL TO SUPPORT MAGISTRATE) on behalf of , Assignor) S.S.#:xxxx-xxPetitioner, -againstRespondent. 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. IF THIS ORDER IS ENTERED BY A JUDGE, PURSUANT TO SECTION 1113 OF THE FAMILY Court ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY THE APPELLANT IN Court, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF THE Court, WHICHEVER IS EARLIEST. IF THIS ORDER IS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTEN OBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS Court WITHIN 30 DAYS OF THE DATE THE ORDER WAS RECEIVED IN Court OR BY PERSONAL American LegalNet, Inc. www.FormsWorkFlow.com Form 4-6 Page 2 SERVICE, OR IF THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER. The above-named Petitioner having filed a petition in this Court, dated alleging that the above-named Respondent is chargeable with the support of , (and) ; 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 having been advised by the Court of the right to counsel, and Respondent having Q denied Q admitted the allegations of the petition; and The name, address and telephone number of Respondent's current employer(s) are: ADDRESS TELEPHONE NAME NOW, after examination and inquiry into the facts and circumstances of the case and G upon application of the Petitioner G upon the Court's own motion, it is ORDERED that the above-named Respondent, upon notice of this order, pay or cause to be paid to [check applicable box]: G Petitioner G Support Collection Unit at , the sum of $ G weekly G every two weeks G monthly Gtwice per month G quarterly, such payments to commence on , allocated as follows: for and toward the support of , spouse, the sum of $ G weekly G every two weeks G monthly Gtwice per month G quarterly and for and toward the support of the child(ren), the sum of $ G weekly G every two weeks G monthly Gtwice per month G quarterly: Name Spouse: Child(ren): Las 4 Digists of Soc. Sec. # Date of Birth Amount Total and it is further 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. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-6 Page 3 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 Q ORDERED that for the following reason(s) constituting good cause pursuant to Section 440(1) of the Family Court Act, the QIV-D cases: Support Collection Unit Q Non-IV-D cases: Court shall NOT issue an immediate income execution; however in the event of default,1 this order shall be enforceable pursuant to Section 5241 of the Court Practice law and Rules, or any other manner provided by law; 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 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 dental, optical, prescription drug and 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 "Default", as defined in CPLR 5241, means the failure to make three payments on the date due in the full amount directed in this order, or the accumulation of arrears, including amounts arising from retroactiv