COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : CHILD SUPPORTPlaintiff(s) SUMMARY REPORT ORDER JUDICIAL SUBPOENA Father’s Name: _______________________________ -against- Mother’s Name: ______________________________ : Cause Number: _______________________________ County: ____________________________________ Date of Order: Summary Report Filed by: 1. 2. 3. 4. : _______________________________ Type of Order (check one): Superior Court : Was the order for child support: Original Order for Support Defendant(s) Number of children of the parties: ______ : ...................................................... List each child’s age below: Child 1 _____ Child 2 _____ Child 3 _____ Father Mother Administrative Law Judge Order Modifying Support Child 4 _____ Complete lines 5-13 using the amounts entered on the child support worksheets signed by the judge/reviewing THE PEOPLE OF THE STATE OF NEW YORK officer. 5. Father’s monthly net income (Support Worksheet Page 1, Line 3) $______________ 6. Mother’s monthly net income (Support Worksheet Page 1, Line 3) $______________ 7. List the basic child support obligation for each child (from Worksheet, Page 1, Line 5, individual amounts) TO Child 1 __________ GREETINGS: Child 2 __________ Child 3 __________ Child 4 __________ 8. Health Care Expenses (Support Worksheet Page 1, Line 8f) $_____________ 9. Day Care WE COMMAND YOU, that all Worksheet Page 2, Line 9) laid aside, you and each of you attend before and Special Expenses (Support business and excuses being , at the Court $_____________ located at County of b. Education Expenses $_____________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed c. adjourned date, to testify and give evidence as a witness in this action on the part of the $_____________ or Long Distance Transportation Expenses the Day Care a. HonorableExpenses d. Other _______________________________ $_____________ e. Other _______________________________ $_____________ 10.a. Father’s standard calculation support obligation (Support Worksheet Page 3, Line 15) $_____________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for Worksheet penalty of $50 b. Mother’s standard calculation support obligation (Supporta maximumPage 3, Line 15)and all damages sustained as a $_____________ result of your failure to comply. Actual Transfer Payment Ordered and Deviation (if any) 11. Which Parent is Payor? Father Mother 12. Witness, Honorable Transfer Payment Amount Ordered by Court Court in County, day of , one of the Justices of the 13. a. If the Court deviated (amount from Line 12 differs from amount on Line 10 for the Payor), was the deviation due to: Child Needs Parental Factors $_____________ , 20 b. If the Court deviated, what were the reasons stated by the Court for the deviation?and type name below) (Attorney must sign above ___________________________________________________________________________________________ ___________________________________________________________________________________________ a. Was post-secondary education provided for? Attorney(s) Yes for No b. If provided for, was a dollar amount ordered? 14. Yes No c. If a dollar amount was ordered, enter Payor’s amount $______________ Answer remaining questions only if this was an order modifying support. Office and P.O. Address 15. Total amount of the support transfer payment on the previous order: $______________ 16. Which parent paid the transfer payment in the previous order? 17. Was the change in the support transfer payment, if any, phased Telephone No.: in? Yes 18. The change in the support order was due to: (check all applicable categories) Change in parent income Facsimile No.: Change in residential schedule Age of children Change in Address: Other E-Mail support schedule Father Mother No Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com WSCSS/Summary Report 06-10-04