F.C.A. §§ 439, 454, 471, 472, 473, 474, 475 476, 477, 478, 479; Art. 5-B Form 4-5a (Undertaking for Support - Cash Deposit) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................................................ In the Matter of a Proceeding for Support Docket No. Petitioner, -againstUndertaking for Support - Cash Deposit Respondent ............................................................................................ WHEREAS an order was entered in the Family Court of the State of New York, County on the day of , 20 , directing the Respondent to post a (written undertaking with sufficient surety approved by the Court)(cash deposit) to be deposited with the (Clerk of the Court) (Support Collection Unit) in the amount of for a period of to secure compliance by the Respondent with an Order of Support dated which order required the Respondent to . NOW THEREFORE, we residing at , Respondent, and residing at , as surety and residing at as surety, are held and firmly bound into the Petitioner herein named, in the sum of lawful money of the United States to be paid to said Petitioner, for which payment well and truly to be made or done we bind ourselves, our heirs, executors and administrators, jointly and severally, firmly by these presents. NOW THEREFORE, the condition of this (undertaking with surety) (cash deposit) is such that the Respondent shall make the support payments to the Petitioner as ordered by the Court in the amount of for the period of then this American LegalNet, Inc. www.FormsWorkFlow.com Form 4-5a Page 2 obligation to be void, and in the event of a failure to make said payments to the Petitioner, said (undertaking with surety) (cash deposit)1 will be used to indemnify the said Petitioner. AND we, the undersigned Respondent and Surety, do hereby STIPULATE, AGREE and CONSENT, that in case the aforesaid Recognizance shall be forfeited, a copy of the order of the Court forfeiting the same, together with this Recognizance, be filed in the office of the Clerk or County Clerk of the County of and that judgment may be entered for the sum set forth in said Recognizance, and that execution issue thereon according to law. Taken and acknowledged before me the day and year first above written, by whom the sureties and penalties are approved. ____________________________________ Respondent ____________________________________ Surety _____________________________________ Surety APPROVAL OF UNDERTAKING The within undertaking is hereby approved both as to form and sufficiency of sureties. Dated: ,. ____________________________ Judge of the Family Court/ Support Magistrate STATE OF NEW YORK ) :ss.: COUNTY OF ) On this day of and , 20 , before me personally came to me known and known to me When cash is posted as surety, the person(s) posting such cash shall, at the expiration of the period for which such security shall have been ordered, be entitled to the return of such cash less any amount which shall have been paid therefrom to the Petitioner by reason of any default(s) in payments on the part of the Respondent. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 4-5a Page 3 to be the individuals described in and who executed the foregoing undertaking, and they severally acknowledged that they executed the same. ___________________________ Clerk of the Family Court Notary Public STATE OF NEW YORK ) :ss.: COUNTY OF ) the within named surety, being duly sworn, says that (s)he is a holder in the said County and is worth dollars over and above all his/she debts and liabilities which (s)he owes or has incurred, and exclusive of property exempt by law from levy and sale under an execution, and that his/her property is in said County of and consists of and that the title to the property above specified is now on record in deponent's own name, in the office of the County Clerk of the County of , and that the same is of the value of not less than dollar, and is assessed for dollars, and is subject to no lien or encumbrances, except and that there are no unsatisfied judgments or executions against his/her , and that (s)he is under no other recognizance, except Sworn to before the Court this day of 20 __________________________________ Surety _________________________ Clerk of the Family Court Notary Public American LegalNet, Inc. www.FormsWorkFlow.com