Fill and Sign the Form 4 24 5 16uifsa 10

F.C.A. §§ 433, 531-a, 580-316 Form 4-24/ 5-16/UIFSA-10 12/2015 ELECTRONIC TESTIMONY APPLICATION AND WAIVER OF PERSONAL APPEARANCE FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ................................................... .......................... In the Matter of a Proceeding for Support or Paternity Under Article 4, 5 or 5-B of the Family Court Act Petitioner, S.S.#: xxxx-xx- -against- DOCKET NO. _____________ Respondent. ELECTRONIC TESTIMONY APPLICATION AND WAIVER OF S.S.#: xxxx-xx- PHYSICAL PRESENCE ................................................... ......................... NOTICE: If you are requesting permission to testify by telephone or by audio-visual or other electronic means, this form must be submitted IMMEDIATELY to the Court at [specify address and fax number of Court]: ___________________________________________________ ___________________________________________ APPLICANT’S NAME: ________________ APPLICANT’S TELEPHO NE: (Home): ( ) ___ - ________ ADDRESS: 1 __________________________ (Work): ( ) ___ - ________ __________________________ (On court date, I can be reached at): ( ) ___ - ________ __________________________ FACSIMILE (Fax): ( ) ___ - _______ ______________ __________________________ E-MAIL: ______________________________ 1. On ________________, I [check applicable box]: ” filed the above-captioned petition in the (Family)(Other [specify]: ) Court, County, State of (New York)(Other [specify] : ). The hearing is scheduled to take place on [specify date]: . ” received a [check applicable box]: ” summons ” subpoena to appear in Family Court, County, State of New York on [specify date]: . 2. I request that I be permitted to testify or to give my depositio n by [check applicable box]: ” telephone ” audio-visual means ” other electronic means (specify): . 3. I am making this request for the following reason(s) [check one or more box(es)]: ” [Non-New York State Residents only ]: I reside in [specify state or jurisdiction]: and am making this request for the following reason(s) [specify]: _ _____________________ ___________________________________________________ _________________________ ___________________________________________________ _________________________ ”“ [New York State residents only]: I reside in County, Ne w York . This county is not the county where the Family Court is located and is not contiguo us to (next to) that county.2 1 Specify if address, telephone or other identifying i nformation has been ordered to be kept confidential pursuant to New York State Domestic Relations Law §§76-h, 254 or Fami ly Court Act §154-b. If your health, safety or liberty or that of your child or children would be put at risk by disclosure of your address or other identifying information, you may a pply for an address confidentiality order by submitting General Form GF-2 1 to this Court. This form is available on-line at www.nycourts.gov . 2 For purposes of this application, the five counties (boroughs) of New York City are treated as one county. Form 4-24/ 5-16/UIFSA-10 Page 2 It would be an undue hardship for me to testify or to be deposed at the Family Court where the case is scheduled to be heard for the following reason(s) [specify]: __ _______________________________ ___________________________________________________ _______________________________ ___________________________________________________ _______________________________ ”“ I am presently incarcerated at [specify facility]: I will be incarcerated on the date on which the hearing or deposition is scheduled and I am not expected to be released until [specify approximate expected date of release]: ____ _________________. 4. I understand that prior to my application being granted, it is my responsibility to arrange a location for my testimony or deposition with the Court. I request that I be per mitted to testify or be deposed from the following location [check applicable box and include all information]: ” The Support Enforcement Agency in my County [specify the name, ad dress and telephone number, including area code]: ___________________________________ _____________________________ ” The Court in my County [specify the name, address and telepho ne number, including area code]: . ” My attorney’s office [specify the name, address and telephon e number, including area code]: ___________________________________________________ _______________________________ ___________________________________________________ ____________________. ” Other location [specify name. address and telephone number, in cluding area code]: I am requesting this location because [state reason]: 5. I understand that I must confirm final arrangements for te stifying by electronic means with this Court by calling the telephone number that will be provided to me. I further under stand that the Court will send me a written Order telling me whether this application has been granted or denied and what number I should call to confirm. Please transmit this order by [check box]: ” e-mail ” facsimile as indicated on the first page of this form. 6. I understand that I have the right to discuss this matter with legal counsel. By this application, I am consenting to the hearing and determination of this matter by this Court without my ph ysical presence. 7. I understand that I have the right to be present at any a nd all appearances, including any hearing scheduled by the Court. I understand that if I fail to appear on any of the sched uled dates, either in person or by telephone, audio- visual means or other electronic means approved by this Court, this Court may hear the matter in my absence or may issue a WARRANT for my arrest. If I am the Petitioner, I understand that if I fail to ap pear, either in person or by telephone, audio-visual means or other electronic means approve d by this Court, the Court may DISMISS my petition. 8. I understand that I must forward to the Court, prior t o my scheduled appearance, the completed financial documentation as requested in the attached summons, as w ell as proof of identity. WHEREFORE, for the reasons stated above, I respectfully request that this a pplication be granted. Dated :________________________. ________________________________________ ” Respondent ” Petitioner ” Witness