: Index No. : Calendar No. BUREAU FOR CHILD SUPPORT ENFORCEMENT : APPLICATION ANDPlaintiff(s) WITHHOLDING FORM INCOME JUDICIAL SUBPOENA -against: This Form MUST Be Completed In All Cases Involving Minor Children or Spousal Support! County: _________________________ Civil Action No. ____________ : Withholding services will begin immediately when the Bureau for Child Support Enforcement : receives this completed application, which MUST be accompanied by a copy of the current Support Order IF one is now : effect. in Defendant(s) ...................................................... ___ Check this blank if a Support Order is NOW in effect. Petitioner Full Name: _________________________ Birth date: _______ SSN: ___________ THE PEOPLE OF THE STATE OF NEW YORK Sex: _____ Relationship to children involved in this case: _______________________________ Residence Address: _____________________________________________________________ TO (List complete physical address: county; city; street #; apt. #; zip code.) Mailing Address: _____________________________________________________________ (List mailing address ONLY if different from physical address.) GREETINGS: Daytime phone #: ____________________ Driver’s License #: ______________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Respondent Full Name: _________________________ Birth date: _______ SSN: ___________ located at County of in _____ , on the day of , at o'clock in the noon, and at any Sex:room Relationship to children involved in , 20 case: _______________________________ recessed this or adjourned date, to testify and give evidence as a witness in this action on the part of the Residence Address: _____________________________________________________________ (List complete physical address: county; city; street #; apt. #; zip code.) Mailing Address: _____________________________________________________________ you liable to Your failure to comply with this subpoena is punishable as a contempt of court and will make the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a (List mailing address ONLY if different from physical address.) result of your failure to comply. Daytime phone #: ____________________ Driver’s License #: ______________________ Witness, Honorable , one of the Justices of the Court in County, , and Dependents ( List full name; sex; birth day of date; social security #;20 custodian for each dependent.) __________________________________________________________________________________ __________________________________________________________________________________ (Attorney must sign above and type name below) ______________________________________________________________________ Income Withholding (List complete address of the employer or other source of for Attorney(s) income to which an Income Withholding Notice should be sent.) ______________________________________________________________________________ Office and P.O. Address ___ Check this blank if YOU WOULD FEAR FOR YOUR SAFETY, or THE SAFETY OF YOUR CHILDREN if your address and telephone number are disclosed. ___ Check this blank if you currently receive TNAF benefits. Telephone No.: CONTINUE ON NEXT PAGE Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com SCA-FC-113 (12/01) Bureau for Child Support Enforcement Application Page 1 of 2 : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : ___ Check this blank if you or one of your children currently receives a DHHS Medical Card. : ___ Check this blank if you currently receive, or have applied for DHHS Child Support Services. : IF YOU CHECKED any of the four items immediately above, skip to the end of the form, SIGN on the line provided, and you are done. Defendant(s) : ...................................................... IF YOU DID NOT CHECK any of the four items immediately above, YOU MUST CONTINUE! ___ I understand that unless otherwise directed by the court, any court ordered support MUST be THE PEOPLE OF THE BCSE through Income Withholding. collected by the STATE OF NEW YORK YOU MUST CHOOSE ONE OF THE THREE FOLLOWING OPTIONS! TO OPTION # 1. ___ I am applying for FULL SERVICES from the BCSE. I understand that full services include, GREETINGS: not limited to the following: *Collection and distribution of support payments. but are *Collection and enforcement of support by income withholding. *Establishment and WE COMMAND YOU, that all *Establishment of paternity. aside, you and of Support Orders enforcement of Support Orders. business and excuses being laid *Enforcementeach of you attend before , the Honorable Federal and State Tax offsets, unemployment compensation intercepts, and workers’ at the Court through located at County of compensation intercepts. *Location of parent(s). *Interstate services. in room , on the day of , 20 , at o'clock in the noon, and at any recessed ___ adjourned date, to testify FULL SERVICES, a AGREE to comply with the following requirements: As an applicant for and give evidence as I witness in this action on the part of the or 1. I understand I MUST assist the BCSE to establish and enforce paternity, child support, and medical support, and to collect child and spousal support. I understand this assistance may include providing information about the non-custodial parent, and responding promptly and Your failure to comply with this subpoena is punishable as completely to requests from the BCSE. I understand I may a contempt ofto testify as a witness inliable to be required court and will make you the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a court, or in other comply. result of your failure to proceedings. 2. I understand that I am free to pursue legal actions through a private lawyer, but that I must inform the BCSE if I do this. Witness, Honorable , one of the Justices of the 3.inI understand that I MUST repay all money received in error to which I am not entitled. Court County, day of , 20 OPTION # 2. ___ I am applying for Income Withholding Services ONLY. (Attorney must sign above and type name below) OPTION # 3. ___ I DID NOT CHECK Option #1 or Option #2. I do not want services from the BCSE at this Attorney(s) for time. ___ I understand that even though I have not requested services at this time, I can request services at any time by applying at the BCSE office in the county in which I live. Office and P.O. Address I CERTIFY that I have read and understand all statements on this application, and that all information I have provided is TRUE and ACCURATE to the best of my knowledge. Telephone Date: Signature: _______________________________________________ No.: ________________ Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com SCA-FC-113 (12/01) Bureau for Child Support Enforcement Application Page 2 of 2