F.C.A. 433, 531-a, 580-316 Form 4-24/ 5-16/UIFSA-10 10/2004 EL EC TR ONIC TES TI MO NY APPLI CAT ION, WAIVER OF PERSO NAL APPEARANCE A ND ORDER FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................................ ..... Petitioner, -against- DOCK ET NO. _____________ Respondent ........................................................................ .... NOTIC E: If you are requesting permission to testify by telephone or by audio-visual or other electronic means, this form must be submitted to the Court at [specify address and fax number of Court]: not less than [check box]: G three days G other period specified by the court [specify]: before the hearing.______________________________________________________________________________________________ APPLICA NTS NAM E: ________________ APPLICA NTS TELEPHONE: (Home): ( ) ___ - ________ADDRESS: __________________________ (Work): ( ) ___ - ________ __________________________ FACSIM ILE (Fax): ( ) ___ - ________ __________________________ E-MAIL: __________________ 1. On ________________, I [check applicable box]: filed the above-captioned petition in the (Family)(Other [specify]: ) Court, County, State of (New York)(Other [specify]: ). The hearing is scheduled to take place on [specify date]: . received a [check applicable box]: summons subpoena to appear in Family Court, County, State of New York on [specify date]: . 2. I request that I be permitted to testify or to give my deposition by [check applicable box]: telephone audio-visual means other electronic means (specify): .3. I am making this request for the following reason(s) [check one or more box(es)]: [Non-New York State Residents Only]: I reside in [specify state or jurisdiction]: and am making this request for the following reason(s) [specify]: ______________________ ________________________________________________________________________ ____ ________________________________________________________________________ ____ I reside in County, New York . This county is not the county where the Family Court 1 is located and is not contiguous to (next to) that county. I am presently incarcerated at [specify facility]: I will be incarcerated on the date on which the hearing or deposition is scheduled and I am not expected to be released until [specify approximate expected date of release]: _____________________. It would be an undue hardship for me to testify or to be deposed at the Family Court where the case is scheduled to be heard for the following reason(s) [specify]: ____________________________________ ________________________________________________________________________ _______________ 4. I understand that prior to my application being granted, it is my responsibility to attempt to arrange with the Support Enforcement Agency in my County or the Court responsible for support enforcement in my County to assist in scheduling my testimony or deposition with the Court. I request that I be permitted to testify or be deposed from the following location [check applicable box and include all information]: American LegalNet, Inc. www.USCourtForms.com 1 For purposes of this application, the five counties (boroughs) of New York City are treated as one county.>>>> 2 Form 4-24/ 5-16/UIFSA-10 Page 2 The Support Enforcement Agency in my County [specify the name, address and telephone number, including area code]: ________________________________________________________________ The Court in my County [specify the name, address and telephone number, including area code]: . My attorneys office [specify the name, address and telephone number, including area code]: ________________________________________________________________________ __________ _______________________________________________________________________. Other location [specify name. address and telephone number, including area code]: I am requesting this location because [state reason]: 5. I understand that I must confirm final arrangements for testifying by electronic means with this Court by calling the telephone number provided on the order below. I further understand that the Court will send me written confirmation of the decision regarding my application, time permitting. 6. I understand that I have the right to legal counsel to discuss this matter. By this application, I am submitting tothe jurisdiction of this Court and I am consenting to the hearing and determination of this matter by this Court without my personal appearance. 7. I understand that I have the right to be present at any and all appearances, including any hearing scheduled by theCourt. I understand that if I fail to appear on any of the scheduled dates, either in person or by telephone, audio- visual means or other electronic means approved by this Court, this Court may hear the matter in my absence or may issue a WARRAN T for my arrest. If I am the Petitioner, I understand that if I fail to appear, either in person orby telephone, audio-visual means or other electronic means approved by this Court, the Court may DISMISS my petition. 8. I understand that I must forward to the Court, prior to my scheduled appearance, the completed financial documentation as requested in the attached summons. Dated:________________________. ________________________________________ Respondent Petitioner WitnessS worn to before me this day of , . ___________________________ (Deputy) Clerk of the Court Notary Public _____________________________________________________________________________________________ ORDER DETERMI NING ELECTRONIC TESTIM ONY APPLICATIO N TO BE FIL LE D OUT BY FAMIL Y COURT : Please be advised that your Electronic Testimony Application is: G Granted. Please be prepared to present your testimony on (date): at (time): as follows: G Please telephone the Court at this number: (___)_________________; G Please be available to receive a call from the Court at telephone number listed in Paragraph 4, above. G Denied for the reasons indicated below: ________________________________________________________________________ _________________ ________________________________________________________________________ _______ If denied, you must personally appear at this Court on the scheduled date and time for the hearing. Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to