Child Support Forms New York State

Referral to Support Magistrate and Temporary Order of Support

F.C.A. §§ 413, 416, 433, 434, 439, 439-a, 440; D.R.L. § 240

Form 4-6a (5/2015)

At a term of the Family Court of the State of New York, held in and for the County of , at New York on .

PRESENT:

Hon.

In the Matter of a Proceeding under Article of the Family Court Act Docket No.

REFERRAL TO SUPPORT MAGISTRATE and TEMPORARY ORDER OF SUPPORT

Petitioner, S.S.#:

-against-

Respondent S.S.#:

NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS FOR CONTEMPT OF COURT OR PROSECUTION FOR CRIMINAL NON-SUPPORT.

YOUR FAILURE TO OBEY THIS ORDER MAY RESULT IN SUSPENSION OF YOUR DRIVER’S LICENSE, STATE-ISSUED PROFESSIONAL, TRADE, BUSINESS AND OCCUPATIONAL LICENSES AND RECREATIONAL AND SPORTING LICENSES AND PERMITS; AND IMPOSITION OF REAL OR PERSONAL PROPERTY LIENS.

A petition in this proceeding, dated: having been filed in this Court, and it appearing that the Court has jurisdiction over the parties and that there is an issue of support; and

Respondent having appeared before this Court to answer the petition and to show why an order of Support and other relief requested in the petition should not be granted; and Respondent, after having been advised of the right to counsel, having denied admitted the allegations of the petition;

The name, address and telephone number of Respondent’s current employer(s) are:

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NOW, after examination and inquiry into the facts and circumstances of the case (and after hearing the proof and testimony offered in relation thereto), it is ORDERED that the above-named Respondent, upon notice of this order, pay or cause to be paid to [specify]: the sum of $ weekly, every two weeks, monthly, twice per month, quarterly

Such payments to commence on allocated as follows: for and toward the support of , spouse, the sum of $

weekly, every two weeks, monthly, twice per month, quarterly and for and toward the support of the child(ren), the sum of $ weekly, every two weeks, monthly, twice per month, quarterly;

ORDERED that, pursuant to Domestic Relations Law §236B(1)(a), payments for the support of the spouse shall terminate upon death of the spouse, upon the spouse’s valid or invalid marriage or upon modification in accordance with Domestic Relations Law §236B(9) or 248; and it is further

ORDERED that commencing on the above-named Respondent pay or cause the above amount(s) to be paid to [check applicable box]: Petitioner by cash, check or money order Non-IV-D cases IV-D cases

[IV-D cases only]: ORDERED that the Respondent, custodial parent and any other individual parties immediately notify the Support Collection Unit of any changes in the following information:

ORDERED that, for the following reason(s) [specify]:

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constituting good cause pursuant to Section 440(1)(b) of the Family Court Act, the IV-D cases: Support Collection Unit Non-IV-D cases: Court shall NOT issue an immediate income execution; however, in the event of default, this order shall be enforceable pursuant to section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; and it is further

ORDERED that this order shall be enforceable pursuant to Section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law;

And the Court having determined that [check applicable box]:

The child(ren) are currently covered by the following health insurance plan [specify]: which is maintained by [specify party]:

Health insurance coverage is available to one of the parents or a legally-responsible relative [specify name]: under the following health insurance plan [specify, if known]:

Health insurance coverage is available to both of the parents as follows:

No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) may be eligible for health insurance benefits under the New York “Child Health Plus” program or New York State Medical Assistance Program, or the publicly funded health insurance program in the State where the custodial parent resides;

No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) are currently enrolled in the New York State Medical Assistance Program.

IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]:

continue to maintain health insurance coverage for the following eligible dependent(s) [specify]:

enroll the following eligible dependent(s) [specify]: under the following health insurance plan [specify]:

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the Medical Execution issued by this Court [Non-IV-D cases]: the Qualified Medical Child Support Order.

The legally-responsible relative(s) shall assign all insurance reimbursement payments for health care expenses incurred for his her eligible dependent(s) to the provider or party having actually incurred and satisfied such expenses, as appropriate;

OR

IT IS THEREFORE ORDERED that the custodial parent [specify name]: shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus” program and the New York State Medical Assistance Program or the publicly funded health insurance program in the State where the custodial parent resides.

And the Court further finds that:

The mother is the custodial non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is ;

The father is the custodial non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is ;

And the Court further finds that [check applicable box];

Each parent shall pay the cost of premiums or family contribution in the same proportion as each of their incomes are to the combined parental income as cited above;

Upon consideration of the following factors [specify]:

Therefore, the payments shall be allocated as follows [specify]:

OR

[Where the child(ren) are recipients of managed care coverage under the New York State Medical Assistance Program] ORDERED that shall pay the amount of $ per toward the managed care premium.

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[Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that shall pay up to an annual maximum of $

pay as part of the cash medical support obligation up to an annual maximum of $ for the calendar year commencing January 1,

ORDERED that shall pay the amount of $ representing his/her share of premiums and/or costs incurred by the New York State Medical Assistance Program from to

ORDERED that in the event that the child(ren) cease(s) to be enrolled in Medicaid, the non-custodial parent’s obligation to pay his/her share of managed care coverage premiums and/or fee-for-service reimbursement shall terminate as of the date the child(ren) is/are no longer enrolled in Medicaid;

ORDERED that the legally responsible relative immediately notify the other party (non-IV-D cases) Support Collection Unit (IV-D cases) of any change in health insurance benefits;

ORDERED, that shall execute and deliver to any forms, documents, or instruments to assure timely payments of any health insurance claim for said defendant(s); and it is further

ORDERED that upon a finding that the legally-responsible relative(s) willfully failed to obtain health insurance benefits, such relative(s) will be presumptively liable for all health care expenses incurred on behalf of the above-named defendant(s).

ORDERED that the legally-responsible relative(s) herein, shall pay his her pro rata share of future reasonable health expenses not covered by insurance by direct payments to the health care provider other

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ORDERED that, if health insurance benefits for the child(ren) become available in the future, such relative(s) shall enroll the eligible dependent(s) immediately and maintain such benefits so long as they remain available.

[Check applicable box(es):

[Where the Court has made a finding that health insurance is not available] ORDERED that an execution for medical support enforcement shall not be issued unless a subsequent determination is made by the court that such benefits are available;

ORDERED that pay the sum of $ as his/her proportionate share of reasonable child care expenses, to be paid as follows:

ORDERED that pay the sum of $ as educational expenses by direct payment to the educational provider other

ORDERED that [specify party or parties; check applicable box(es): purchase and maintain life and/or accident insurance policy in the amount of maintain the following existing life and/or accident insurance policy in the amount of

assign the following as beneficiary/beneficiaries: to existing life and/or accident insurance policy or policies:

The obligation to provide such insurance shall cease upon termination of the duty of to provide support for each child;

[IV-D cases only]: ORDERED that when family assistance is no longer received, support payments shall continue to be made to the Support Collection Unit, unless otherwise requested;

ORDERED that the Respondent is directed to:

seek employment

participate in job training, employment counseling, or other programs designed to lead to employment [specify program]:

ORDERED that Respondent shall have the following rights of visitation with respect to the child(ren) [specify]:

[REQUIRED] IT IS FURTHER ORDERED that a copy of this order be provided promptly by:

Support Collection Unit (IV-D cases) Clerk of Court (non-IV-D cases) to the New York State Case Registry of Child Support Orders.

ORDERED, that the issue of support is hereby referred to a Support Magistrate for final determination pursuant to Sections 439 and 439-a of the Family Court Act; and it is further

ORDERED that

Check applicable box:

Order mailed on [specify date(s) and to whom mailed]:

Order received in court on [specify date(s) and to whom given]:

INFORMATION CONCERNING COST OF LIVING ADJUSTMENTS AND MODIFICATIONS

(1) THIS ORDER OF CHILD SUPPORT 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 THIS ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED...

(2) A RECIPIENT OF FAMILY ASSISTANCE SHALL HAVE THE CHILD SUPPORT ORDER REVIEWED AND ADJUSTED...

(3) WHERE ANY PARTY FAILS TO PROVIDE AND UPDATE A CURRENT ADDRESS...

(4) IN ADDITION TO A COST OF LIVING ADJUSTMENT, EACH PARTY HAS A RIGHT TO SEEK A MODIFICATION OF THE CHILD SUPPORT ORDER...

PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS...