COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BUREAU FOR CHILD SUPPORT ENFORCEMENT : Index No. APPLICATION AND INCOME WITHHOLDING FORM : Calendar No. This Form MUST Be Completed In All Cases Involving Minor Children or Spousal Support! Plaintiff(s) County: _________________________ -against- : JUDICIAL SUBPOENA 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 in effect. ___ Check this blank if a Support Order is NOW in effect.: Defendant(s) : Petitioner . .Full .Name:. _________________________ .Birth .date: _______ SSN: ___________ ........ ... ..... ........................... .... . Sex: _____ Relationship to children involved in this case: _______________________________ Residence Address: _____________________________________________________________ THE PEOPLE OF THE STATE OFphysical address: county; city; street #; apt. #; zip code.) (List com plete NEW YORK Mailing Address: _____________________________________________________________ TO (List mailing address O NLY if different from physical address.) Daytime phone #: ____________________ Driver’s License #: ______________________ GREETINGS: Respondent Full Name: _________________________ Birth date: _______ SSN: ___________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Sex: Honorable this case: _______________________________ the _____ Relationship to children involved in at the Court located at County of Residence Address: on the _____________________________________________________________any recessed in room , day of , 20 , at o'clock in the noon, and at (List and give evidence as a county; city; street #; apt. the part of or adjourned date, to testifycom plete physical address:witness in this action on #; zip code.)the Mailing Address: _____________________________________________________________ (List mailing address O NLY if different from physical address.) Daytime phone failure to comply with this subpoena is punishable as a______________________ Your #: ____________________ Driver’s License #: contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your List full nam e; sex; Dependents ( failure to comply. birth date; social security #; and custodian for each de pendent.) __________________________________________________________________________________ Witness, Honorable , one of the Justices of the __________________________________________________________________________________ Court in County, day of , 20 ______________________________________________________________________ Income Withholding (Attorney must sign above which name below) (List com plete address of the employer or other source of income to and typean Income W ithholding Notice should be sent. ) ______________________________________________________________________________ Attorney(s) for ___ 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. Office and P.O. Address CONTINUE ON NEXT PAGE SCA -FC-11 3 (12/01) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Bureau for Child Support Enforcement Application Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. ___ Check this blank if you or one of your children currently receives a DHHS Medical Card. : JUDICIAL SUBPOENA Plaintiff(s) ___ Check this blank if you currently receive, or have applied: for DHHS Child Support Services. -againstIF 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. : IF YOU DID NOT CHECK any of the four items immediately above, YOU MUST CONTINUE! Defendant(s) : ___ . . . .I .understand .that .unless .otherwise .directed. by .the .court,. any court ordered support MUST be .. ......... ... ..... ........ ...... .. .. .... collected by the BCSE through Income Withholding. YOU MUST CHOOSE ONE OF THE THREE FOLLOWING OPTIONS! THE PEOPLE OF THE STATE OF NEW YORK OPTION # 1. TO ___ I am applying for FULL SERVICES from the BCSE. I understand that full services include, but are not limited to the following: *Collection and distribution of support payments. *Collection and enforcement of support by income withholding. *Establishment and enforcement of Support Orders. *Establishment of paternity. *Enforcement of Support Orders GREETINGS: through Federal and State Tax offsets, unemployment compensation intercepts, and workers’ compensation intercepts. that all business and excuses being laid aside, you and each of you attend before WE COMMAND YOU, *Location of parent(s). *Interstate services. ___ Honorable , the As an applicant for FULL SERVICES, I AGREE to comply with the following requirements: at the Court located BCSE to establish and enforce paternity, child support, and County I understand I MUST assist the at 1. of in room , on the day of , 20 , at o'clock in this noon, and at medical support, and to collect child and spousal support. I understandthe assistance mayany recessed or adjourned providing information evidence as a witness in this actionand the part of the date, to testify and give about the non-custodial parent, on responding promptly and include completely to requests from the BCSE. I understand I may be required to testify as a witness in court, or in other proceedings. 2. I understand that I am free to pursue legalis punishable as a contempt of court and will make you liable to Your failure to comply with this subpoena actions through a private lawyer, but that I must the party on the BCSE if Ithis this. inform whose behalf do subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 3. I understand that I MUST repay all money received in error to which I am not entitled. Witness, Honorable OPTION # 2. Court I County, day of , 20 ___ inam applying for Income Withholding Services ONLY. , one of the Justices of the OPTION # 3. (Attorney must sign from the BCSE at this ___ I DID NOT CHECK Option #1 or Option #2. I do not want servicesabove and type name below) 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. Attorney(s) for 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. Office and P.O. Address Signature: _______________________________________________ Date: ________________ SCA -FC-11 3 (12/01) Telephone No.: Facsimile No.: E-Mail Address: Bureau for Child Support Enforcement Application Mobile Tel. No.: Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com