Fill and Sign the 455 Art Form

F.C.A.§ 455; Art. 5-B Form 4-15 [NOTE : Personal Information Form 4-5/5-1d, (Relief from Support Payments containing social security numbers of parties and and Commitment ) dependents, must be filed with this Petition] 8/2010 FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF......................................................................................... In the Matter of a Proceeding for Support under Article (4)(5-B) of the Family Court Act Docket No. (Commissioner of Social Services, Assignee, on behalf of , Assignor) Petitioner, PETITION FOR RELIEF FROM SUPPORT -against- PAYMENTS AND COMMITMENT Respondent. .......................................................................................... TO THE FAMILY COURT: The undersigned respectfully alleges that: 1. , was the Petitioner and that [specify]: was the Respondent in the above-entitled proceeding. 2. a. An Order of Support, dated [specify]: , was entered by the Family Court, County. b. [Delete if inapplicable]: An Order of Commitment, dated [specify]: , was entered by the Family Court, County. 3. The name(s) and date(s) of birth of the child(ren) are: Name Date of Birth 4. (Upon information and belief) The Respondent is financially unable to comply with the Order of Support because [state facts]: 5. [Delete if inapplicable]: Respondent failed to make application from relief from the Order of Support because [state facts]: . 6. 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 Form 4-15 Page 2 WHEREFORE Respondent requests that G he Gshe be relieved Gentirely Gpartially from making any payment of the order of support and from the order of commitment and for such other and further relief as the Court may deem just and proper. 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 COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF LIVING ADJUSTMENT SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE 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) RECEIVING FAMILY ASSISTANCE SHALL HAVE A CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY. ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT 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 TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTED OCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ADJUSTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED 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