F.C.A. §§ 439, 454, 471, 472, 473, 474, 475 Form 4-5a
476, 477, 478, 479; Art. 5-B (Undertaking forSupport - CashDeposit)
8/2010
FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF........................................................................................
In the Matter of a Proceeding for Support Docket No.
Petitioner,
-against- Undertaking forSupport - CashDeposit
Respondent
............................................................................................ WHEREAS an order was entered in the Family Court of the State of New York,
County on the day of , 20 , directing the
Respondent to post a (written undertaking with sufficient surety approved by the Court)(cash deposit)
to be deposited with the (Clerk of the Court) (Support Collection Unit) in the amount of
for a period of to secure compliance by the Respondent with an Order ofSupport
dated which order required the Respondent to . NOW THEREFORE, we residing at , Respondent, and
residing at ,
as surety and residing at
as surety, are held and firmly bound into the Petitioner herein named, in the sum of lawful
money of the United States to be paid to said Petitioner, for which payment well and truly to be made
or done we bind ourselves, our heirs, executors and administrators, jointly and severally, firmly by
these presents.
NOW THEREFORE, the condition of this (undertaking with surety) (cash deposit) is such
that the Respondent shall make the support payments to the Petitioner as ordered by the Court in the
amount of for the period of then this
Form 4-5a Page 2
obligation to be void, and in the event of a failure to make said payments to the Petitioner, said
(undertaking with surety) (cash deposit) will be used to indemnify the said Petitioner. 1
AND we, the undersigned Respondent and Surety, do hereby STIPULATE, AGREE and
CONSENT, that in case the aforesaid Recognizance shall be forfeited, a copy of the order of the Court
forfeiting the same, together with this Recognizance, be filed in the office of the Clerk or County Clerk
of the County of and that judgment may be entered for the sum set forth in said Recognizance, and that
execution issue thereon according to law.
Taken and acknowledged before me the day and year first above written, by whom the sureties
and penalties are approved.
____________________________________ Respondent
____________________________________
Surety
_____________________________________ Surety
APPROVAL OF UNDERTAKING
The within undertaking is hereby approved both as to form and sufficiency of sureties.
Dated: ,.
____________________________
Judge of the Family Court/ Support Magistrate
STATE OF NEW YORK ) :ss.:
COUNTY OF )
On this day of , 20 , before me personally came and to me known and known to me
W hen cash is posted as surety, the person(s) postin g such cash shall, at the
1
expiration of the period for w hich such security sh all have been ordered, be entitled to the
return of such cash less any amount w hich shall hav e been paid therefrom to the
Petitioner by reason of any default(s) in paym ents on the part of the R espondent.
Form 4-5a Page 3
to be the individuals described in and who executed the foregoing undertaking, and they severally
acknowledged that they executed the same. ___________________________
Clerk of the Family Court Notary Public
STATE OF NEW YORK ) :ss.:
COUNTY OF )
the within named surety, being duly sworn, says that (s)he is a
holder in the said County and is worth dollars over and above all his/she debts
and liabilities which (s)he owes or has incurred, and exclusive of property exempt by law from levy
and sale under an execution, and that his/her property is in said County of
and consists of and that the title to the property
above specified is now on record in deponent's own name, in the office of the County Clerk of the
County of , and that the same is of the value of not less than dollar,
and is assessed for dollars, and is subject to no lien or encumbrances, except
and that there are no unsatisfied judgments or executions against
his/her , and that (s)he is under no other recognizance, except
Sworn to before the Court this
day of 20 __________________________________Surety
_________________________
Clerk of the Family Court Notary Public