Fill and Sign the 432 424 571 S Form

F.C.A. §§ 415, 416, 421, 422, Form 4-3a432, 424, 571; S.S.L. §§ 101, 102 (Support)C.P.L.R. 5242 6/2012[NOTE: Personal Information Form 4-5/5-1d, containing social security numbers of parties anddependents, must be filed with this Petition]FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF...................................................................................In the Matter of a Proceeding for Docket No.Support under Article 4 of the Family Court Act(Commissioner of Social Services, Assigneeon behalf of , Assignor) Petitioner, PETITION (Commissioner) -against-Respondent. ...........................................................................TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that:1. Petitioner is Commissioner of Social Services whose official address is in the County of , State of New York and is authorized to originate this proceeding (asassignee) 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 support proceeding but has assigned her/his rightto do so to the Commissioner of Social Services pursuant to the Social Services Law of the State ofNew York. In the event the assignment ends the assignor may pursue support and may seek an order ofsupport.3. (Upon information and belief) (Assignor) and Respondent were married aton , .)4. Respondent is chargeable with the support of the following: Name Date of BirthSpouse: Child(ren)5. (Upon information and belief) Respondent, on or about , , and since that date, has failed to provide fair and reasonable support for the above-named dependent(s) according toRespondent's means and earning capacity. Form 4-3a page 2[Check boxes if applicable; delete paragraphs 5 and/or 6 if inapplicable]: 6.Respondent is unlikely to make payments in accordance with the order of supportrequested, because of G past lack of financial responsibility G credit references G credit history G other [specify]: 7. Respondent has the following source of income: Gemployer Gincome payor, asdefined in CPLR Sec.5241(a), whose name and address are [specify]: 8. No previous application has been made to any judge or court, including a NativeAmerican tribunal, or is presently pending before any judge or court, for the relief requested in thispetition (exceptWHEREFORE, Petitioner requests an order for support directing Respondent to pay fair and 1reasonable support payable to the Commissioner of Social Services or, in the event that the assignmentends, payable to the ex-assignor, requiring Respondent to exercise the option of additional coveragefor health insurance in favor of (his) (her) above-named child(ren), and for such other and further reliefas the law provides.NOTE:(1) A COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDINGCOMMENCED BY THIS APPLICATION (PETITION) SHALL BEADJUSTED BY THE APPLICATION OF A COST OF LIVINGADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTIONUNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCHORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THEREQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TOPARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT SHALLBE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THECOST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BEHEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THECOURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDERIN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THEFAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDSACT. (2) A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVINGFAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDERREVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORTCOLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHSAFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTEDBY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHERAPPLICATION BY ANY PARTY. ALL PARTIES WILL RECEIVE A COPYOF THE ADJUSTED ORDER. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANYCHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENTADDRESS, AS REQUIRED BY SECTION FOUR HUNDREDPursuant to Section 111-g of the Social Services Law, where an order of support directs 1that support payments be made to the support collection unit of a social services district, thepetition in such proceeding shall be deemed to be an application for support services. Form 4-3a page 3FORTY-THREE OF THE FAMILY COURT ACT, TO WHICH ANADJUSTED ORDER CAN BE SENT, THE SUPPORT OBLIGATIONAMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING Form 4-3a page 4ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OFTHE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTEDOCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ADJUSTEDORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HASRECEIVED A COPY OF THE ADJUSTED ORDER. ______________________________________Petitioner______________________________________Print or type name______________________________________Signature of Attorney, if any______________________________________Attorney’s Name (Print or Type)__________________________________________________________________________________________________________________Attorney’s Address and Telephone Number