Fill and Sign the Fca413 416 424 425 Form 4 2 439 439a

F.C.A.§§ 413, 416, 439(e)Form 4-SM.-3(Support – Findings of Fact)8/2010FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF.............................................................................................In the Matter of a Proceeding for Support Docket No. (Commissioner of Social Services, Assignor,on behalf of , Assignee)FINDINGS OF FACTPetitioner-against-Respondent.............................................................................................. , being the Support Magistrate before whom the issues of support in the above-entitled proceeding were assigned for determination, makes the following findings of fact: [checkapplicable boxes]:1.Petitioner and Respondent were:Qmarried on [specify date]: , andQare still husband and wifeQwere divorced on [specify date]:Qnever married to each other. 2.QThe following children were born of this marriage [specify]:QThere are no children born of this marriage.3. Qa.Respondent is liable for the support of the following child(ren): [specify]:Name of ChildChild’s Date of Birthb.The basis of, or reason for, Respondent’s liability is [specify]:QRespondent is not liable for the support of the children.4.a.The following child(ren) [state name(s)]:reside with Petitioner.b.The following child(ren) [state name(s)]: reside with Respondent.5.a. Petitioner:Qfiled a net worth statement or financial disclosure affidavit.Qdid not file a net worth statement or financial disclosure affidavit and Qdid Qdid not have good cause for not filing.b.Respondent: Qfiled a net worth statement or financial disclosure affidavit.Qdid not file a net worth statement or financial disclosure affidavit and Qdid Qdid not have good cause for not filing.6.The basic child support obligation for support of the following child(ren) [specify name(s)]:________________________________________________________________________________is $ __________ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly.7.The mother is the Qcustodial Qnon-custodial parent, whose pro rata share of the basicchild support obligation is $ __________ Qweekly Qevery two weeks QmonthlyQtwice per month Qquarterly.8.The father is the Qcustodial Qnon-custodial parent, whose pro rata share of the basicchild support obligation is $ __________ Qweekly Qevery two weeks QmonthlyQtwice per month Qquarterly..9.QPetitioner has available health insurance coverage under [specify plan]:This plan:Qcovers the following children [specify]:with the following contribution or premium paid by Petitioner$ ______ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly.Qcan be extended to cover the following children [specify]:with the following contribution or premium paid by Petitioner$ ______ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly.This plan contains the following benefits: QmedicalQdentalQprescriptiondrugsQoptical Qother health care benefits [specify]: ________________________QRespondent has available health insurance coverage under [specify plan]:This plan:Qcovers the following children [specify]:with the following contribution or premium paid by Petitioner$ ______ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly. Qcan be extended to cover the following children [specify]:with the following contribution or premium paid by Petitioner$ ______ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly.This plan contains the following benefits: QmedicalQdentalQprescriptiondrugsQoptical Qother health care benefits [specify]: ________________________QNeither Petitioner nor Respondent have available health insurance coverage.10.a. Health insurance coverage for the children is ordered as follows:QPetitioner is directed to continue the health insurance coverage for the followingchild(ren) [specify]:with costs to be allocated between the parties asfollows [specify]:QPetitioner is directed to enroll the following child(ren) [specify]: in the above-named health insurance plan, effective [specify date]: ,with costs to be allocated between the parties as follows [specify]:QRespondent is directed to continue the health insurance coverage for the followingchild(ren) [specify]:with costs to be allocated between the parties asfollows [specify]:QRespondent is directed to enroll the following child(ren) [specify]: inthe above-named health insurance plan, effective [specify date]: , withcosts to be allocated between the parties as follows [specify]:QThe custodial parent [specify]: shall immediately apply toenroll the child(ren) in the NYS "Child Health Plus Program" or the New York StateMedical Assistance Program or the publicly funded health insurance program in theState where the custodial parent resides. If the child(ren) is/are accepted into the "Child Health Plus Program," the cost of the premiums or family contribution shall beallocated between the parties as follows: b. The allocation between the parties of costs of medical premiums or contributions inparagraph a :Qis prorated in the same proportion as each parent’s income is to the combinedparental income.Qis not prorated in the same proportion as each parent’s income is to the combinedparental income, because that would be unjust or inappropriate for the followingreason(s) [specify]: ORc.Q[Where the child(ren) are recipients of coverage under the managed care coverageunder the New York State Medical Assistance Program] i.The monthly premium for managed care coverage under the New York StateMedical Assistance Program is $________. ii.The monthly amount that would be required as a family contribution underthe state's child health insurance plan pursuant to title one-a of articletwenty-five of the public health law (Child Health Plus) for the child(ren) ifthey were in a two-parent household with income equal to the combinedincome of the non-custodial and custodial parents is $________.iii.Five percent (5%) of the non-custodial parent’s gross income is $________.iv.The non-custodial parent’s obligation for managed care coverage under theNew York State Medical Assistance Program is $________.v.QThe obligation for managed care coverage under the New York StateMedical Assistance Program would reduce the non-custodial parent’sincome below the self-support reserve. Therefore the non-custodial parent’sobligation is $________.vi.QThe non-custodial parent’s obligation for managed care coverage underthe New York State Medical Assistance Program is for the period from______________ to _____________ is $________.Q[Where the child(ren) are recipients of coverage under fee for service coverage underthe New York State Medical Assistance Program] i.The annual amount that would be required as a family contribution under thestate's child health insurance plan pursuant to title one-a of article twenty-five of the public health law (Child Health Plus) for the child(ren) if theywere in a two-parent household with income equal to the combined incomeof the non-custodial and custodial parents is $________.ii.Five percent (5%) of the non-custodial parent’s gross income is $________.iii.The non-custodial parent’s obligation for fee for service coverage under theNew York State Medical Assistance Program is $________ annually.iv.The non custodial parent’s obligation for fee for service coverage under theNew York State Medical Assistance Program for the balance of the currentcalendar year is $________.v.QThe obligation for fee for service coverage under the New York StateMedical Assistance Program would reduce the non-custodial parent’sincome below the self-support reserve. Therefore the non-custodial parent’sobligation is $________ annually. The non custodial parent’s obligation forthe balance of the current calendar year is $________.v.QThe non-custodial parent’s obligation for fee for service coverage underthe New York State Medical Assistance Program is for the period from______________ to _____________ is $________.11.The non-custodial parent’s pro rata share of the basic child support obligation is:Qordered without deviation;Qwould be Q unjust Q inappropriate, based upon consideration of the following factor(s) in Family Court Act §413(l)(f) [specify factor(s) and reason(s)]:12.[Applicable only where the parties have agreed or stipulated to an order of child support,pursuant to Family Court Act §413(1)(h)]: Q The parties have voluntarily stipulated to child support for the followingchild(ren)[specify]:payable by [specify]:to [specify]:in the amount of $ __________ Qweekly Qevery two weeks Qmonthly Qtwice per month Qquarterly, such stipulation having been entered into the record andreciting, in compliance with Section 413(l)(h) of the Family Court Act that:a.The parties have been advised of the provisions of Section 413(l) of the Family CourtAct;b.The unrepresented party, if any, has received a copy of the child support standards chartpromulgated by the Commissioner of the New York State Office of Temporary andDisability Assistance pursuant to Section 111-i of the Social Services Law;c.The basic child support obligation as defined in Family Court Act Section 413(l)presumptively results in the correct amount of child support to be awarded; andd.The parties' reason(s) for agreeing to child support in an amount different from the basicchild support obligation (is)(are) [specify]:13.[Applicable to determinations of petitions for wilful violation under F.C.A.§454]:a.QRespondent willfully failed to obey the order of this Court as follows [specify]:QRespondent did not willfully fail to obey the order of this Court.b.QRespondent showed the following good cause for failing to make application forrelief from the judgment or order directing payment of support prior to the accrual ofthe alleged arrears: [set forth facts and circumstances constituting good cause; seeF.C.A. §451]:QRespondent did not show good cause for failing to make application for relief fromthe judgment or order directing payment of support prior to the accrual of the allegedarrears.c.QThe request for the following relief [specify]:is denied for the following reasons(s) [specify; see F.C.A. §454]: 14.[Applicable in petitions for modification]:QThe following facts constitute a change of circumstances [specify]: QNo change in circumstances has been found.15.The following appendices are attached and made a part of these Findings of Fact:QAppendix AQAppendix BQOther [specify]:16.The following are additional findings of fact:1Dated:________________________________________Support Magistrate These may include, among others: potential for support; other child support obligations; support 1payments previously made; efforts to supplement income; efforts to find employment; and findingsregarding child care, educational expenses and accident and life insurance. Appendix AItemization of Income and Deductions of Custodialand Non-Custodial Parents[Family Court Act §§413( l)(b), 413(1)(c), 413(1)(f), 416]CUSTODIAL PARENTQMother QFatherGross (Total) Income1.Gross (total) income (as should have been or should be reported in most recent federal income tax return)$__________2.Investment income (not already included in item 1), reduced by sums expended in connection with the investments $__________3.Income or compensation voluntarily deferred orincome from the following sources (not alreadyincluded in items 1 or 2)a.deferred compensation $__________b.worker's compensation $__________c.disability benefits $__________d.unemployment insurance benefits $__________e.social security benefits $__________f.veterans benefits $__________g.pensions and retirement benefits $__________h.fellowships and stipends $__________i.annuity payments $__________4.Income based upon former resources or income $__________5.Self-employment deductions (not already includedin items 1 or 2)a.depreciation deduction $__________b.entertainment and travel allowances $__________6.Other $__________ 2________________________________________7.GROSS INCOME$__________ See Family Court Act Section 413, subd. l(b)(5)(iv) and (v) 2 Deductions8.Unreimbursed employeebusiness expenses (except to extent expenses reduce personal expenditures)$__________9.Alimony or maintenance actually paid tonon-party spouse pursuant to courtorder or agreement $__________10.Alimony or maintenance actually paid or to bepaid to party-spouse pursuant to court orderor agreement $__________11.Child support actually paid pursuant to court orderor agreement for non-party child $__________12. Family assistance $__________13.Supplemental Security Income $__________14.N.Y.C. or Yonkers income taxes $__________15.Federal Insurance Contributions Act (FICA) taxes $__________16. TOTAL DEDUCTIONS$__________Health Insurance: Insurance available? Qyes Qno17.CUSTODIAL PARENT'S NET INCOME$__________ NON-CUSTODIAL PARENTQMother QFatherGross (Total) Income1.Gross (total) income (as should have been or should be reported in most recent federal income tax return)$__________2.Investment income (not already included in item 1), reduced by sums expended in connection with the investments $__________3.Income or compensation voluntarily deferred orincome from the following sources (not alreadyincluded in items 1 or 2)a.deferred compensation $__________b.worker's compensation $__________c.disability benefits $__________d.unemployment insurance benefits $__________e.social security benefits $__________f.veterans benefits $__________g.pensions and retirement benefits $__________h.fellowships and stipends $__________i.annuity payments $__________4.Income based upon former resources or income $__________5.Self-employment deductions (not already includedin items 1 or 2)a.depreciation deduction $__________b.entertainment and travel allowances $__________6.Other $__________ 3________________________________________7.GROSS INCOME$__________ See Family Court Act Section 413, subd. l(b)(5)(iv) and (v) 3 Deductions8.Unreimbursed employeebusiness expenses (except to extent expenses reduce personal expenditures)$__________9.Alimony or maintenance actually paid tonon-party spouse pursuant to courtorder or agreement $__________10.Alimony or maintenance actually paid or to bepaid to party-spouse pursuant to court orderor agreement $__________11.Child support actually paid pursuant to court orderor agreement for non-party child $__________12.Family assistance $__________13.Supplemental Security Income $__________14.N.Y.C. or Yonkers income taxes $__________15.Federal Insurance Contributions Act (FICA) taxes $__________16. TOTAL DEDUCTIONS$__________Health Insurance: Insurance available? Qyes Qno17.NON-CUSTODIAL PARENT'S NET INCOME$__________ Appendix BItemization of Income and Deductions of Custodialand Non-Custodial Parents[FCA §§413( l)(a), 413(1) (b), 413(1)(c), 413(1)(f)]1.Petitioner's Qweekly Qmonthly expenses are: [itemize]:2.Petitioner's Qweekly Qmonthly sources of income are: [itemize]:3.Respondent's Qweekly Qmonthly expenses are: [itemize]:4.Respondent's Qweekly Qmonthly sources of income are: [itemize]:5.The Qweekly Qmonthly needs of the following children are: [itemize as to each child]: