Fill and Sign the 111 K Form

F.C.A. Article 4,S.S.L.§ 111-k;Form 4-18a Public Health Law§ 4135-b (Petition for Support Aft er [ NOTE : Personal Information Form 4-5/5-1-d, Acknowledgme nt Of containing social security numbers of parties and P aternity–Commissioner) dependents, must be filed with this Petition] 6/2012 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ................................................... ......................................... .. In the Matter of a Proceeding for Support Under Article Of the Family Court Act Docket N o. Commissioner of Social Services, Assignee PETITION F OR on behalf of , Assignor SUPPORT AFTER ACKNOWLEDGMENT Petitioner, OF PATERNIT Y (COMMISSIONER) -against- Respondent. ................................................... ........................................ TO THE FAMILY COURT: 1. Petitioner is the Commissioner of Social Services whose official address is , in the County of State of New York and is authorized to originate th is proceeding pursuant to the Social Services Law and the Family Court Act of the State of New York. 2. The assignor is authorized to originate a suppo rt proceeding but has assigned her/his right to do so to the Commissioner of Social Services pur suant to the Social Services Law of the State of New York. In the event the assignment ends the assi gnor may pursue support and may seek an order of support. 3. (Upon information and belief) (Assignor) on e xecuted an acknowledgment of paternity pursuant to Social Services Law §111 K and Public Health Law § 4135-b acknowledging that [check applicable box]: Gshe is the mother Ghe is the biological father of [specify child]: , who was born out of wedlock on [specify date]: in [specify location]: The acknowledgment also stated that [specify other parent]: is the G mother G father of the child. Form 4-18a Page 2 4. The name(s) and date(s) of birth of the child(ren) are: Name Date of Birth 5. The Respondent is chargeable with the support of the above-named child in that (she) (he) duly executed an acknowledgment of pater nity pursuant to SSL§ 111-K and P.H.L.§ 4135-b on acknowledging that [check applicable box]: G she is the mother Ghe is the biological father of the child. 6 . The acknowledgment G has G has not been filed with the appropriate registrar of birth records and a copy Gis G is not attached to this petition and made a part of it. 7. (Upon information and belief) Respondent, on or about , , and after that date, has failed to pro vide fair and reasonable support for the child according to Respondent's means and earn ing capacity. [Check boxes if applicable; delete paragraphs 7 and /or 8 if inapplicable]: 8. Respondent's G past financial responsibility G credit references Gcredit history and G other [specify]: make it unlikely that Respondent will make paym ents in accordance with the order of support requested in t his petition. 9. Respondent has an Gemployer Gincome payor, as defined in CPLR Sec.5241(a), whose name and address are [specify]: , as a source of income. 10. No previous application has been made to any judge or court, including a Native American tribunal, or is presently pending before any judge or court, for the relief requested in this petition except: WHEREFORE, Petitioner requests an order for support 1 directing Respondent to pay fair and reasonable support payable to the Commissioner of Social Services or, in the event the assignment ends, payable to the ex-assignor, requiring Respond ent to exercise the option of additional coverage for health insurance in favor of his above-named child( ren), and for such other and further relief as the law provides. 1 Pursuant to Section 111-g of the Social Services L aw, where an order of support directs that support payments be made to the support collection unit of a social services district, the petition in such proceeding shall be deemed to be an application for support services. Form 4-18a Page 3 NOTE: (1) A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) SHALL BE ADJUSTED BY THE APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTI ON UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UP ON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMEN T SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJ ECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH TH E COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT. (2) A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) REC EIVING FAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPO RT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTH S AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY. ALL PARTIES WIL L RECEIVE A COPY OF THE ADJUSTED ORDER. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE U PON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURR ENT ADDRESS, AS REQUIRED BY SECTION FOUR HUNDRED FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERM S OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTE D OCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ADJ USTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER. _______________________________ Petitioner ___________________________________ Print or type name Form 4-18a Page 4 ___________________________________ Signature of Attorney, if any ___________________________________ Attorney’s Name (Print or Type) ___________________________________ ___________________________________ ___________________________________ Attorney’s Address and Telephone Number