F.C.A. § 523 [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 Paternity Proceeding Under Article of the Family court Act (Commissioner of Social Services, Assignee, on behalf of , Assignor) Petitioner, -againstRespondent. ................................................................................ TO FAMILY COURT: The undersigned Petitioner respectfully shows that: 1. Form 5-3 (Paternity) 6/2012 Docket No. PATERNITY PETITION (Social Services Official) Petitioner is a Social Services official of the G County G City of [specify]: , whose official address is [specify]: 2. The assignor is authorized to originate a paternity proceeding but has assigned her right to do so to the Commissioner of Social Services pursuant to the Social Services Law of the State of New York. In the event the assignment ends, the assignor may seek a declaration of paternity, order of filiation and order of support. 3. Upon information and belief, [specify name of mother or mother-to-be]: , who resides at 1 gave birth to a G male G female child out of wedlock on or about [specify date] , at . The child resides with at [specify, unless ordered confidential]: . G Unless ordered confidential, pursuant to Family Court Act § 154-b, because disclosure would pose an unreasonable risk to the health or safety of the mother or mother-to-be. See Forms GF-21 and 21a, available at www.nycourts.gov. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 5-3 Page 2 G 4. Name is pregnant with a child which is likely to be born out of wedlock. The name and date of birth of the child are: Date of Birth 5. Upon information and belief, the above-named Respondent, who resides at [specify]: 2 , is the father of the child. 6. At the time of conception of the child, the mother G was not married G was married to [name] address is [specify]: G is , whose last known 7. Upon information and belief, the moth er and/or child [check applicable box]: G is likely to become a public charge on the GCounty [specify]: G City of [specify]: . 8. No individual has been adjudicated father of this child, either in this court, or any other court, including a Native American court; and no individual has signed an Acknowledgment of Paternity admitting paternity for this child, (except) [specify]: 9. The subject child Gis Gis not a Native-American child subject to the Indian Child Welfare Act of 1978 (25 U.S.C. § 1961-1963). 10. Upon information and belief, no previous application has been made to any court or judge for the relief requested herein except [specify]: WHEREFORE, Petitioner requests that this Court issue a summons or warrant requiring the Respondent to show cause why the Court should not enter a declaration of paternity, order of filiation, order of support3 payable to the Commissioner of Social Services or, in the event the assignment ends, payable to the ex-assignor, and 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 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 Unless ordered confidential, pursuant to Family Court Act § 154-b, because disclosure would pose an unreasonable risk to the health or safety of the Respondent. See Forms GF-21 and 21a, available at www.nycourts.gov. Pursuant to Section 111-g of the Social Services Law, where an order of support directs that support payments be made to the support collection unit of a social services district, the petition in such proceedings shall be deemed to be an application for support services. American LegalNet, Inc. www.FormsWorkFlow.com 2 3 Form 5-3 Page 3 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 TWENTY-FOUR 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 Form 5-3 Page 4 VERIFICATION IN PROCEEDING BY GOVERNMENTAL AGENCY STATE OF NEW YORK COUNTY OF ) : ss.: ) being duly sworn, deposes and says: That (s)he is and is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)he has read the foregoing petition and knows the contents thereof; that the same is true to (his)(her) own knowledge except as to those matters therein stated to be alleged upon information and belief, and that as to those matters (s)he believes it to be true. ________________________ Petitioner Sworn to before me this day of ,. __________________________________ (Deputy) Cler