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F.C.A. §§ 413, 440, 442-447, Form 4-11a449, 451, 461, 466, 467 (Support- Order Extending, Modifying or Terminating Order of Support Made by Family Court or Another Court) 5/2015At a term of the Family Court of theState of New York, held in and forthe County of , at , New York on , .P R E S E N T:Hon. Judge/Support Magistrate ................................................................................In the Matter of a Proceeding for Docket No.Support under Article 4 of the Family (Commissioner of Social Services, Assignee, ORDER ON PETITION TOon behalf of , Assignor)G EXTENDG MODIFYG TERMINATE AN Petitioner,ORDER OF SUPPORTMADE BYS.S. #: xxxx-xx- G FAMILY COURT G ANOTHER COURT -against- RespondentS.S.#: xxxx-xx- ................................................................................ NOTICE:YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN COMMITMENT TO JAIL FOR A TERM NOT TOEXCEED SIX MONTHS FOR CONTEMPT OF COURT OR PROSECUTION FOR CRIMINAL NON-SUPPORT. YOURFAILURE TO OBEY THIS ORDER MAY RESULT INSUSPENSION OF YOUR DRIVER’S LICENSE, STATE-ISSUEDPROFESSIONAL, TRADE, BUSINESS AND OCCUPATIONALLICENSES AND RECREATIONAL AND SPORTING LICENSESAND PERMITS; AND IMPOSITION OF REAL OR PERSONALPROPERTY LIENS.IF THIS ORDER WAS ENTERED BY A JUDGE, THE ORDERMAY BE APPEALED PURSUANT TO SECTION 1113 OF THEFAMILY COURT ACT. THAT SECTION PROVIDES THAT ANAPPEAL FROM THAT ORDER MUST BE TAKEN WITHIN 30DAYS AFTER RECEIPT OF THE ORDER BY THE APPELLANTIN COURT, 30 DAYS AFTER SERVICE BY A PARTY OR THE Form 4-11a page 2ATTORNEY FOR THE CHILD UPON THE APPELLANT, OR 35DAYS FROM THE DATE OF MAILING OF THE ORDER TOAPPELLANT BY THE CLERK OF THE COURT, WHICHEVER ISEARLIEST.IF THIS ORDER WAS ENTERED BY A SUPPORTMAGISTRATE, SPECIFIC WRITTEN OBJECTIONS TO THISORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYSOF THE DATE THE ORDER WAS RECEIVED IN COURT OR BYPERSONAL SERVICE, OR IF THE ORDER WAS RECEIVED BYMAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER. The petition having been filed in this Court seeking to Q terminate Q extend Q modify aQ judgment Qorder, dated , , granting support made by the Q Supreme Court of theState of New York, County, entitled Index No. Q Family Court of County Q Other court: ; and[Check applicable box(es)]: Q It appearing that under the terms of the Q judgment Q order the Q Supreme Court Q Other [specify]: Q has Q has not retained exclusive jurisdiction tomodify the Q judgment Q order; and Q It appearing that the Court is a court of competent jurisdictionoutside the State of New York; andQ It appearing that [check applicable box(es)]:: Q there has been a substantial change of circumstances since the entry of theQjudgment Qorder; Q there has been a change in excess of 15% in income since the entry of the QjudgmentQorder and the parties had not opted out of this ground for modification in a validly executedwritten agreement or stipulation;1 Q three years have elapsed since the entry of the Qjudgment Qorder and the parties hadnot opted out of this ground for modification in a validly executed written agreement or stipulation;2 Q no grounds exist in accordance with Family Court Act §451(2) or DomesticRelations Law §236B(9)(b)(2) for seeking a modification of child support; The matter having duly come on to be heard before this Court, NOW, afterexamination and inquiry into the facts and circumstances of the case, and after hearing theproofs and testimony, the Court finds that;1 This ground only applies to original or modified support orders entered on or after October 13, 2010. 2 This ground only applies to original or modified support orders entered on or after October 13, 2010. Form 4-11a page 3The basic child support obligation for support of the following child(ren) is$____________ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly:NAMEDATE OF BIRTHSOC. SEC. # (last 4 digits)AMOUNTThe mother is the Qcustodial Q non-custodial parent, whose pro rata share of the basicchild support obligation is $_______________;The father is the Qcustodial Qnon-custodial parent, whose pro rata share of the basic childobligation is $ ___________ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly;And the Court finds further that:G The non-custodial parent's pro rata share of the basic child support obligation is neitherunjust nor inappropriate; 3 ORG Upon consideration of the following factors specified in Family Court Act §413(1)(f): the non-custodial parent's pro rata share of the basic child support obligation is: G unjust G inappropriate;4[Applicable in cases in which the parties stipulated to an order of child support]:Q And the Court finds that the parties have voluntarily stipulated to child support for thechild(ren)[names] __________________________________________ payable by________________________ in the amount of $____________ Q weekly, Q every two weeks, Q monthly, Q twice per month, Q quarterly. Q This stipulation has been entered into the record and recites, in compliance withFamily Court Act § 413(1)(h), that:a. The parties have been advised of the provisions of Family Court Act §413(1);b. The unrepresented party, if any, has received a copy of the Child Support Standardschart promulgated by the Commissioner of the N.Y.S. Office of Temporary and DisabilityAssistance pursuant to Social Services Law § 111-i;c. The basic child support obligation as defined in Family Court Act Section 413(1)presumptively results in the correct amount of child support to be awarded;d. The basic child support obligation in this case is $__________ G weekly G every twoweeks G monthly Gtwice per month G quarterly; and e. The parties' reason(s) for agreeing to child support in an amount different from the3This paragraph is to be used if the basic child support obligation is applied without deviation. 4This paragraph is to be used only if the court's order deviates from the basic child supportobligation, pursuant to F.C.A.§ 413(1)(g). Form 4-11a page 4basic child support obligation (is) (are) [specify]: ;G The Court approves the parties' agreement to deviate from the basic child supportobligation for the following reasons: [specify; see Family Court Act Section 413(1)(f)]: ; The name, address and telephone number of Q Respondent’s Q (modification only): Petitioner’s current employer(s), are:NAMEADDRESS TELEPHONENOW, therefore, it is herebyG ORDERED that the petition for modification is DENIED.ORG ORDERED that the Q judgment Qorder, dated , , isTERMINATED; G ORDERED that the Qjudgment Q order dated , , is CONTINUEDuntil further order of this Court;G ORDERED that the Q judgment Qorder, dated , , is MODIFIED inthe following respects [specify]: G AND the defaulting party having Q shown Qfailed to show good cause for failure tomake an application for relief from the judgment or order directing payment prior to the accrual ofthe arrears, it isG ORDERED that arrears in the amount of $ are Q annulled Qreduced to $ Q fixed at the full amount of $ ; and it is further G ORDERED that judgment be entered in favor of the Petitioner against the Respondentin the amount of $ ,  plus interest [CPLR 5004] from , , in theamount of $ ,  plus costs and disbursements in the amount of $ , for a totalsum of $ ; and it is further G ORDERED and ADJUDGED that the above-named Q Respondent Q Petitioner isresponsible for the support so ordered from the date of the filing of the petition to the date of thisOrder Q less the amount of $ already paid, and that the Q Respondent Q Petitioner shallpay the sum of $ as follows: $ immediately, $ Q weekly, Q everytwo weeks, Q twice per monthly, Q quarterly, to [check applicable box]: Form 4-11a page 5 G Petitioner by cash, check or money order G Respondent by cash, check or money order G Non-IV-D cases: Payable to the Petitioner by check or money order and mailed to the NYSChild Support Processing Center P. O. Box 15365, Albany, NY 12212-5365. The county name forthe matter must be included with the payment for identification purposes. G IV-D cases: Payable by check or money order made payable to and mailed to the NYS ChildSupport Processing Center, PO Box 15363, Albany, NY 12212-5363. The county name and NewYork Case Identifier number for the matter must be included with the payment for identificationpurposes; and it is further[Non-IV-D cases only]: G ORDERED that, pursuant to Family Court Act Section440(1)(b)(2), this order shall be enforceable by immediate income deduction order issued inaccordance with Section 5242(c) of the Civil Practice Law and Rules; and it is furtherG ORDERED that, for the following reason(s)constituting good cause pursuant to Section 440(1)(b) of the Family Court Act, the G IV-D cases:Support Collection Unit G Non-IV-D cases: Court shall NOT issue an immediate incomeexecution; however, in the event of default,6 this order shall be enforceable pursuant to section5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; and it isfurther[IV-D cases only]: G ORDERED that the Respondent, custodial parent and any otherindividual parties immediately notify the Support Collection Unit of any changes in the followinginformation: residential and mailing addresses, social security number, telephone number, driver’slicense number; and name, address and telephone numbers of the parties’ employers and any changein health insurance benefits, including any termination of benefits, change in the health insurancebenefit carrier or premium, or extent and availability of existing or new benefits; And the Court having determined that [check applicable box]:G The child(ren) are currently covered by the following health insurance plan [specify]: which is maintained by [specify party]:G 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]: which provides the following health insurance benefits [specify extent and type of benefits, if known, including any medical, any medical dental, optical, prescription drug and health careservices or other health care benefits]:G Health insurance coverage is available to both of the parents as follows:6 “Default”, as defined in CPLR 5241, means the failure to make three payments on the date due in the fullamount directed in this order, or the accumulation of arrears, including amounts arising from retroactive support, thatare equal to or greater than the amount directed to be paid for one month, whichever occurs first. Form 4-11a page 6 Name Health Insurance Plan Premium or ContributionBenefitsG No legally-responsible relative has health insurance coverage available for the child(ren), but thechild(ren) may be eligible for health insurance benefits under the New York “Child HealthPlus” program or the New York State Medical Assistance Program, or the publicly funded healthinsurance program in the State where the custodial parent resides, G No legally-responsible relative has health insurance coverage available for the child(ren), but thechild(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)]: G continue to maintain health insurance coverage for the following eligible dependent(s)[specify]: under the above-named existing plan for as long as it remainsavailable; G enroll the following eligible dependent(s) [specify]:under the following health insurance plan [specify]: immediately and without regard to seasonal enrollment restrictions and maintain such coverage aslong as it remains available in accordance with[IV-D cases]: G the Medical Execution, which shall be issued immediately by the Support Collection Unit, pursuant to CPLR 5241 G the Medical Execution issued by this Court[Non-IV-D cases]: G the Qualified Medical Child Support Order. Such coverage shall include all plans covering the health, medical, dental, optical andprescription drug needs of the dependents named above and any other health care services orbenefits for which the legally-responsible relative is eligible for the benefit of such dependents;provided, however, that the group health plan is not required to provide any type or form of benefitor option not otherwise provided under the group health plan except to the extent necessary to meetthe requirements of Section 1396(g-1) of Title 42 of the United States Code. The legally-responsible relative(s) shall assign all insurance reimbursement payments for health care expensesincurred for (his)(her) eligible dependent(s) to the provider of such services or the party havingactually incurred and satisfied such expenses, as appropriate;ORIT IS THEREFORE ORDERED that the custodial parent [specify name]: shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus”program (the NYS health insurance program for children) and the New York State MedicalAssistance Program or the publicly funded health insurance program in the State where the custodialparent resides, it is hereby. And the Court further finds that: Form 4-11a page 7The mother is the Q custodial Q non-custodial parent, whose pro rata share of the cost orpremiums to obtain or maintain such health insurance coverage is ;The father is the Q custodial Q non-custodial parent, whose pro rata share of the cost orpremiums to obtain or maintain such health insurance coverage is ;And the Court further finds that [check applicable box]:G Each parent shall pay the cost of premiums or family contribution in the same proportionas each of their incomes are to the combined parental income as cited above; G Upon consideration of the following factors [specify]: pro-rating the payment would be unjust or inappropriate for the following reasons [specify]: Therefore, the payments shall be allocated as follows [specify]: ; and it is furtherORG [Where the child(ren) are recipients of managed care coverage under the New York StateMedical Assistance Program] ORDERED that , the non-custodial parent herein,shall pay the amount of $ per toward to the managed care premium under theNew York State Medical Assistance Program;G [Where the child(ren) are recipients of fee-for-service coverage under the New York StateMedical Assistance Program] ORDERED that , the non-custodial parentherein, shall pay up to an annual maximum of $ for the current calendar year to theNew York State Medical Assistance Program upon written notice that the program has paid healthcare expenses on behalf of the child(ren) for costs incurred during the current calendar year.G [Where the child(ren) are recipients of fee-for-service coverage under the New York StateMedical Assistance Program] ORDERED that , the non-custodial parentherein, pay as part of the cash medical support obligation up to an annual maximum of $ for the calendar year commencing January 1, and for every year thereafter to the NewYork State Medical Assistance Program upon written notice that the Medicaid program has paidhealth care expenses on behalf of the child(ren).G ORDERED that , the non-custodial parent herein, shall pay theamount of $ , representing his/her share of premiums and/or costs incurred by the NewYork State Medical Assistance Program for the period of time from to thedate of this order, which amount shall be support arrears/past due support;G ORDERED that in the event that the child(ren) cease(s) to be enrolled in the New York StateMedical Assistance Program, the non-custodial parent’s obligation to pay his/her share of managedcare coverage premiums and/or fee-for-service reimbursement shall terminate as of the date thechild(ren) is/are no longer enrolled in Medicaid; Form 4-11a page 8ORDERED that the legally responsible relative immediately notify the [check applicable box]:G other party (non-IV-D cases) G Support Collection Unit (IV-D cases) of any change in healthinsurance benefits, including any termination of benefits, change in the health insurance benefitcarrier or premium, or extent and availability of existing or new benefits; and it is further ORDERED that [specify name]: shall execute and deliver to[specify name]: any forms, notices, documents, or instruments to assuretimely payments of any health insurance claims for said dependent(s); and it is further ORDERED that upon a finding that the above-named legally-responsible relative(s) willfullyfailed to obtain health insurance benefits in violation of [check applicable box(es)]: G this orderG the medical execution G the qualified medical child support order, such relative(s) will bepresumptively liable for all health care expenses incurred on behalf of the above-nameddefendant(s) from the first date such dependent(s) Q was Q were eligible to be enrolled to receivehealth insurance benefits after the issuance of such order or execution directing the acquisition ofsuch coverage; and it is furtherORDERED that [specify]: the legally-responsiblerelative(s) herein, shall pay Q his Q her pro rata share of future reasonable health expenses of thechild(ren) not covered by insurance by [check applicable box]: G direct payments to the health careprovider G other [specify]: ; and it is further ORDERED that, if health insurance benefits for the above-named child(ren) are not available atthe present time become available in the future to the legally-responsible relative(s), such relative(s)shall enroll the dependent(s) who are eligible for such benefits immediately and without regard toseasonal enrollment restrictions and shall maintain such benefits so long as they remain available; and it is further[Check applicable box(es): G [Where the Court has made a finding that health insurance is not available] ORDERED that anexecution for medical support enforcement shall not be issued by the support collection unit unless asubsequent determination is made by the Court that such health insurance benefits are available; and it is furtherG ORDERED that , the non-custodial parentherein, pay the sum of $ as Q his Q her proportionate share of reasonable childcare expenses, to be paid as follows: ; and it is furtherG ORDERED that , the non-custodial parent herein, pay the sum of $ as educational expenses by G direct payment to the educational Form 4-11a page 9provider G other [specify]: ; and it is furtherG ORDERED that [specify party or parties; check applicable box(es):Gpurchase and maintain G life and/or G accident insurance policy in theamount of [specify]: (and/or)Gmaintain the following existing G life and/or G accident insurance policy in theamount of [specify]: (and/or)Gassign the following as G beneficiary G beneficiaries [specify]: to the following existing G life and/or G accident insurance policy or policies[specify policy or policies and amount(s)]: .In the case of life insurance, the following shall be designated as irrevocable beneficiaries[specify]: during the following time period [specify]: .In the case of accident insurance, the insured party shall be designated as irrevocable beneficiaryduring the following time period [specify]: .The obligation to provide such insurance shall cease upon the termination of the duty of [specifyparty]: to provide support for each child;. and it is furtherG ORDERED that the support obligor (the non-custodial parent) is directed to:7 G seek employmentG participate in job training, employment counseling, or other programs designed to lead toemployment [specify program]:; and it is further[IV-D cases only}: G ORDERED that when the person or family to whom familyassistance is being paid, no longer receives family assistance, support payments shall continue to bemade to the Support Collection Unit, unless such person or family requests otherwise;) and it isfurther[REQUIRED] IT IS FURTHER ORDERED that a copy of this order be providedpromptly by [check applicable box]:G Support Collection Unit ((IV-D cases: ) G Clerk of Court(non-IV-D cases) to the New York State Case Registry of Child Support Orders establishedpursuant to Section 111-b(4-a) of the Social Services Law; and it is furtherORDERED that [specify]: ENTER_________________________________________ G Judge of the Family Court G Support Magistrate)Dated:7 Inapplicable where support obligor is receiving SSI or social security disability benefits. See FCA §437-a. Form 4-11a page 10Check 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 APPLICATIONOF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORTCOLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER THISORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OFANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH ( 2) BELOW. UPONAPPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THESUPPORT COLLECTION UNIT, AN ADJUSTED ORDER SHALL BE SENT TO THEPARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALLHAVE THIRTY-FIVE (35) DAYS FROM THE DATE OF MAILING TO SUBMIT AWRITTEN OBJECTION TO THE COURT INDICATED ON SUCH ADJUSTED ORDER. UPON RECEIPT OF SUCH WRITTEN OBJECTION, THE COURT SHALL SCHEDULE AHEARING AT WHICH THE PARTIES MAY BE PRESENT TO OFFER EVIDENCEWHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDERIN ACCORDANCE WITH THE CHILD SUPPORT STANDARDS ACT. (2) A RECIPIENT OF FAMILY ASSISTANCE SHALL HAVE THE CHILD SUPPORTORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORTCOLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCHORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED WITHOUT FURTHERAPPLICATION OF ANY PARTY. ALL PARTIES WILL RECEIVE NOTICE OFADJUSTMENT FINDINGS. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE,THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS TO WHICH ANADJUSTED ORDER CAN BE SENT AS REQUIRED BY SECTION 443 OF THE FAMILY COURT ACT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALLBECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDERTHE TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED ANDADJUSTED OCCURRING ON OR AFTER THE EFFECTIVE DATE OF THE ORDER,REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THEADJUSTED ORDER.(4) IN ADDITION TO A COST OF LIVING ADJUSTMENT, EACH PARTY HAS A RIGHTTO SEEK A MODIFICATION OF THE CHILD SUPPORT ORDER UPON A SHOWINGOF: (I) A SUBSTANTIAL CHANGE IN CIRCUMSTANCES; OR (II) THAT THREEYEARS HAVE PASSED SINCE THE ORDER WAS ENTERED, LAST MODIFIED ORADJUSTED; OR (III) THERE HAS BEEN A CHANGE IN EITHER PARTY'S GROSS Form 4-11a page 11INCOME BY FIFTEEN PERCENT OR MORE SINCE THE ORDER WAS ENTERED,LAST MODIFIED, OR ADJUSTED; HOWEVER, IF THE PARTIES HAVE SPECIFICALLYOPTED OUT OF SUBPARAGRAPH (II) OR (III) OF THIS PARAGRAPH IN A VALIDLYEXECUTED AGREEMENT OR STIPULATION, THEN THAT BASIS TO SEEKMODIFICATION DOES NOT APPLY.