F.C.A. §542; Art.5-B Form 5-6a (Paternity-Temporary Order of Support on Default) 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 , . P R E S E N T: Hon. Judge/Support Magistrate ............................................................................ In the Matter of a Paternity Proceeding (Commissioner of Social Services, Assignee) on behalf of ,Assignor) Petitioner, S.S.#: xxxx-xx-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. The above-named Petitioner having filed a petition, sworn to on , , alleging that the above-named QAssignor Q Respondent is the father of a Q male Q female child [insert child's name and LAST four digits of the social security number]: born out of wedlock to on , , and that Q the mother and/or child is or is likely to become a public charge; and The Respondent having appeared before this Court to answer the petition, having been advised by the Court of the right to counsel and having been ordered to show cause why a declaration of paternity, order of support and other relief requested in the petition should not be made; and the Respondent having denied the allegations of the petition; and The Court having ordered the administration and analysis of a genetic marker test pursuant to Section(s) Q418 Q532 QArt.5-B of the Family Court Act; and TEMPORARY ORDER OF SUPPORT ON DEFAULT Docket No. American LegalNet, Inc. www.FormsWorkFlow.com Form 5-6a Page 2 Q The Respondent having willfully failed to appear before this Court subsequent to the administration and analysis of such test, which does not exclude the Q Respondent Q Assignor as being the father of the child, it is therefore Q The Respondent having willfully failed to comply with the order directing submission to such test, and having also willfully failed to appear before this court on the adjourned date, it is therefore Q ORDERED that commencing on [specify]: the above-named Respondent, upon notice of this order, pay or cause to be paid the sum of $ G weekly G every two weeks G monthly Gtwice per month G quarterly 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 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; The name, address and telephone number of Respondent's current employer(s), are: NAME ADDRESS TELEPHONE 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 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 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 Plan Premium or Contribution Benefits American LegalNet, Inc. www.FormsWorkFlow.com Form 5-6a Page 3 G No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) may be eligible for health insurance benefits under the New York "Child Health Plus" program or the New York State Medical Assistance Program, or the publicly funded health insurance program in the State where the custodial parent resides, G No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) are currently enrolled in the New York State Medical Assistance Program. IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]: G continue to maintain health insurance coverage for the following eligible dependent(s) [specify]: under the above-named existing plan for as long as it remains available; G enroll the following eligible dependent(s) [specify]: under the following health insurance plan [specify]: immediately and without regard to seasonal enrollment restrictions and maintain such coverage as long as it remains available in accordance with [IV-D cases]: G the Medical Execution, which shall be issued immediately by the Support Collection Unit, pursuant to CPLR 5241 G the Medical Execution issued by this Court [Non-IV-D cases]: G the Qualified Medical Child Support Order. Such coverage shall include all plans covering the health, medical, dental, optical and prescription drug needs of the dependents named above and any other health care services or benefits for which the legally-responsible relative is eligible for the benefit of such dependents; provided, however, that the group health plan is not required to provide any type or form of benefit or option not otherwise provided under the group health plan except to the extent necessary to meet the requirements of Section 1396(g-1) of Title 42 of the United States Code. The legally-