IMPORTANT NOTICE TO COURT CLERKS FOR ALL NON-IV-D ORDERS: THIS FORM, RATHER THAN THE CHILD SUPPORT ORDER, SHOULD BE MAILED BY THE COURT TO THE STATE CASE REGISTRY, PO BOX 15101, ALBANY, NY 12212-5101 New York State Case Registry Filing Form For Use With Child Support Orders and Combined Child and Spousal Support Orders Payable To Other Than A Child Support Collection Unit* * Domestic Relations Law § 240(5) and Family Court Act § 440(5) direct that such orders be promptly provided to the State Case Registry. The Office of Temporary and Disability Assistance has indicated that the information sought on this form satisfies the requirement to maintain a record of the order pursuant to Social Services Law § 111-b(4-a)(a)(2) and no order is to be filed unless specifically requested. Note: Full Social Security Numbers are required on this form. Redaction is not allowed. Name of Court: Child Support Payor: (first) Child Support Payee: (first) County Name: (last) (last) Index/Docket No: (middle initial) Social Security #: (Payor) Date of Birth: (Payor) (middle initial) Social Security #: (Payee) Date of Birth: (Payee) Date of Birth: (Child #1) Child #1 Name: (first) (last) (middle initial) Social Security #: (Child #1) Child #2 Name: (first) (last) (middle initial) Social Security #: (Child #2) Date of Birth: (Child #2) Child #3 Name: (first) (last) (middle initial) Social Security #: (Child #3) Date of Birth: (Child #3) (If more children, please use additional form.) The order expires on:  the youngest child’s 21st birthday or _______________________ (MM/DD/YYYY). FAMILY VIOLENCE INQUIRY Has a Temporary or Final Order of Protection been granted on behalf of either party? If yes, which party -  Payor  Payee Has a request for confidentiality of address been granted on behalf of either party?  Payee If yes, which party -  Payor rev. 8.12  yes  no  yes  do not know  no American LegalNet, Inc. www.FormsWorkFlow.com