Fill and Sign the F C A522 523 Form 5 1 Ssl 111 G Paternity

F.C.A. §§ 523; S.S.L. 111 -g Form 5-2 [ NOTE : Personal Information Form 4 -5/5-1-d, (Paternity Petition --) containing social security numbers of parties and Person Other Than dependents, must be filed with this Petition] Parent; Representative of Society) 10/2016 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .............................................................................................. In the Matter of a Paternity Proceeding Docket No. Petitioner, PATERNITY PETITION - against- (Person other than Parent; Representative Respondent. of Society) ............................................................................................... TO THE FAMILY COURT: The undersigned petitioner respectfully shows t hat: 1. (a) Petitioner is [check applicable box]: □ guardian of □ a person standing in a parental relation to □ next of kin of the child named below. Petitioner resides at [specify]: 1 (b) Petitioner is a duly authori zed representative of , an incorporated society doing charitable and/or philanthropic work, which maintains its office at . 2. Upon information and belief, [specify name of mother or mother- to-be]: who resides at [specify]: 2 1 Unless ordered confidential, pursuant to Family Court Act § 154-b, because disclosure would pose an unreasonable risk to the health or safety of the Petitioner. See Forms GF -21 and 21a, available at www.nycourts.gov. 2 Unless ordered confidential, pursuant to Family Court Act § 154-b, because disclosure would pose an unreasonable risk to the health or safety of the mother or mother -to -be. See Forms GF-21 and 21a, available at www.nycourts.gov. Form 5-2 Page 2 □ gave birth to a ❑ male ❑ female child out of wedlock on or about the day of , and said child resides with at . □ is pregnant with a child who is likely to be born out of wedlock. (c) The name and date of birth of the child are: Name Date of Birth 3. Upon information and belief, the above-named Respondent, who resides at [specify]: 3 , is the father of said child. 4. [check boxes if applicable]: The Respondent has acknowledged paternity of the child □ in writing □ by furnishing support. 5. At the time of conception of the child, the mother: □ was not married. □ was married to [specify]: whose last known address is [specify]: 6. No individual has been adjudicated father of this child, either in this court, or any other court, including a Native-American court; and no individual has signed an Acknowledgment of Paternity admitting paternity for this child (except) [specify]: 7. I am hereby applying for child support services from the Support Collection Unit (the IV -D program pursuant to Title 6-A of the Social Services Law) through the f iling of this Petition, unless [Check a box only if applicable]: □ I have already applied for child support services from the Support Collection Unit (the IV- D program pursuant to Title 6-A of the Social Services Law) □ I do not need to apply now because I have continued to receive child support services after the public assistance or care case, or foster care case, for my family has closed. 3 Unless ordered and confidential, pursuant to Family Court Act § 154-b, because disclosure would pose an unreasonable risk to the health or safety of the Respondent. See Forms GF-21 and 21a, available at www.nycourts.gov. Form 5-2 Page 3 □ I do not wish to apply for child support services. □ I am not eligible to apply for child support services because I am petitioning for spousal support only. 8. The subject child □ is □ is not a Native-American child subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). 9. No previous application has been made to any court or judge for the relief requested (except [specify]: WHEREFORE, Petitioner requests that this Court issue a summons or warrant requiring the Respondent to show cause why the Court should not enter a declaration of paternity, an order of support and such other and further relief as may be appropriate under the circumstances. NOTE: (1) A COURT ORDER OF SUPPO RT 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 Form 5-2 Page 4 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. Dated: , . _____________________________ Petitioner _____________________________ Print or type name _____________________________ Signature of Attorney, if any _____________________________ Attorney’s Name (Print or Type) _____________________________ _____________________________ _____________________________ Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK) ): ss.: COUNTY OF ) __________________________, being duly sworn, says that (s)he is the Petitioner in the above- entitled proceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters herein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. ________________________ Petitioner Sworn to before me this day of , . ________________________________ (Deputy) Clerk of the Court Notary Public Form 5-2 Page 5 AGENCY VERIFICATION STATE OF NEW YORK) ): ss.: COUNTY OF ) _________________________. being duly sworn, deposes and says: That (s)he is _____________________________ and is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)he has read the foregoing petition and knows the contents thereof; that the same is true to (his)(her) own knowledge except as to those matters therein stated to be alleged upon information and belief, and that as to those matters (s)he believes it to be true. ________________________ Petitioner Sworn to before me this day of , . ________________________________ (Deputy) Clerk of the Court Notary Public