F.C.A.§ 413, Art.5-BForm 4- SM-1(Stipulation for Child Support) 6/2012FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF..........................................................................................(Commissioner of Social Services, Assignee,on behalf of , Assignor) Petitioner, STIPULATION FORS.S.#: xxxx-xx- CHILD SUPPORT -against- Docket No.Respondent.S.S.#: xxxx-xx- .........................................................................................1. The parties to this stipulation are: , the mother,and , the father of the following child(ren) [Listnames, dates of birth, of each child]:NAME DATE OF BIRTH2. A petition seeking support for the above-named child(ren) was filed by, , Petitioner, against , Respondent, in the FamilyCourt, County, on , ,3. As otherwise indicated in the court record, the parties appeared today Gwith Gwithout counsel before Support Magistrate and indicated that theywish voluntarily to make a stipulation for the support of the above-named child(ren) as permittedby Section 413(l)(h) of the Family Court Act.Accordingly, the parties stipulate as follows:a. They are aware of the provisions of the Child Support Standards Act, Section 413(l)and 416 of the Family Court Act, and that the basic child support obligation as defined Section413(1) is the presumptively correct amount of child support.b. They are aware of the provisions of Section 416 of the Family Court Act regardingaccident, life and health insurance, including the requirement that a party provide health
Form 4-SM-1 Page 2insurance, if available. The parties voluntarily agree to waive the issuance by the Court of aseparate order with respect to provision of [check applicable box(es)]: Gaccident Glifeinsurance. The parties voluntarily agree to the issuance of a G IV-D case: medical execution GNon-IV-D case: Qualified Medical Child Support Order Gwaive the issuance of a medicalexecution or order.c. 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 and DisabilityAssistance pursuant to Section 111-i of the Social Services Law.d. The amount of the basic child support obligationfor the child(ren) in this case is $ G weekly G every two weeks G monthlyGtwice per month G quarterly. e. The parties agree that the amount of child support to be ordered in this proceeding is $ , per to be paid by to .as follows:Name Date of Birth Amount Total:f. The parties' reason(s) for agreeing to child support in an amount different from thebasic child support obligation (is) (are): [specify; see Family Court Act § 413(l)(f)]: ;g. The Court approves the parties' agreement to deviate from the basic child supportobligation for the following reasons: [see Family Court Act Section 413(1)(f)]:h. The name, address and telephone number of Respondent’s current employer(s), are:NAMEADDRESS TELEPHONE i. The parties agree that the Respondent is chargeable with the support of the followingperson(s) and is possessed of sufficient means and able to earn such means to provide thepayment of the sum $ G weekly G every two weeks G monthly Gtwice permonth G quarterly, such payments to commence on , , allocated as
Form 4-SM-1 Page 3follows for and toward the support of Respondent’s spouse and children as follows:Name Date of Birth Amount Per Time Period 1spouse:child(ren): Total:j. The parties agree that payments for the support of Respondent’s spouse shall terminateupon the death of the spouse; and it is furtherk. The parties agree that the Respondent is responsible for the support so ordered fromthe date of the filing of the petition to the date of this Order (less the amount of $ already paid) and that the Respondent pay the sum of $ as follows: $ immediately, and $ G weekly G every two weeks G monthly Gtwice permonth G quarterly; and it is further l. The parties agree that commencing on _______________________ the Respondent,upon notice of this Order, shall pay or cause the above amount(s) to be paid to G Petitioner 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 countyname for the 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 nameand New York Case Identifier number for the matter must be included with the paymentfor identification purposes; and it is furtherm. [IV-D cases only]: The parties agree that the Respondent, custodial parent and anyother individual parties shall immediately notify the Support Collection Unit of any changes inthe following information: residential and mailing addresses, social security number, telephonenumber, driver’s license number; and name, address and telephone numbers of the parties’employers and any change in health insurance benefits, including any termination of benefits,change in the health insurance benefit carrier or premium, or extent and availability of existing ornew benefits; and it is furthern. The parties agree that [specify]: shall pay to [specify]: , the attorney for the other party, the sum of $ for counsel fees in thisproceeding, which payment may be made in installments of $ G weekly G every twoweeks G monthly Gtwice per month G quarterly , commencing on [specify]: , , until the entire sum is paid; Specify whether support amount is weekly, every two weeks, monthly, twice per month or quarterly. 1
Form 4-SM-1 Page 4o. The parties agree 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 extentand type of benefits, if known, including any medical, dental, optical, prescription drug andhealth care services or other health care benefits]:G Health insurance coverage is available to both of the parents as follows: Name Health Insurance Plan Premium or Contribution BenefitsG No legally-responsible relative has health insurance coverage available for the child(ren), butthe child(ren) may be eligible for health insurance benefits under the New York “ChildHealth Plus” program or the New York State Medical Assistance Program, or the publicly fundedhealth insurance program in the State where the custodial parent resides.G No legally-responsible relative has health insurance coverage available for the child(ren), butthe child(ren) are currently enrolled in the New York State Medical Assistance Program,p. The parties agree that [specify name(s) of legally-responsible relative(s)]: G shall continue to maintain health insurance coverage for the following eligibledependent(s) [specify]: under the following plan [specify]:for as long as it remains available; G shall 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 coverageas long 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 5241G 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
Form 4-SM-1 Page 5benefit or option not otherwise provided under the group health plan except to the extentnecessary to meet the 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 healthcare expenses incurred for (his)(her) eligible dependent(s) to the provider of such services or theparty having actually incurred and satisfied such expenses, as appropriate;ORG The parties agree that the custodial parent [specify name]: shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus” program (theNYS health insurance program for children) or the New York State Medical Assistance Programor the publicly funded health insurance program in the State where the custodial parent resides.q. The parties agree that [check applicable box(es)]: (i)The mother is the Q custodial Qnon-custodial parent, whose pro rata share of thecost or premiums 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 ;G Each parent shall pay the cost of premiums or family contribution in the sameproportion as each of their incomes are to the combined parental income as cited above; G Because pro-rating the payment would be unjust or inappropriate for the followingreasons [specify factors]: the payments shall be allocated as follows [specify]:OR[Applicable to children receiving managed care Medicaid coverage]: (ii) G Because the child(ren) are recipients of managed care coverage under theNew York State Medical Assistance Program, the parties agree that [specify]: , the non-custodial parent herein, shall pay the amount of $ per towardto the managed care premium under the New York State Medical Assistance Program;OR[Applicable to children receiving fee-for-service Medicaid coverage]: (iii) G Because the child(ren) are recipients of fee-for-service coverage under theNew York State Medical Assistance Program, the parties agree that [specify]:,the non-custodial parent herein, shall pay up to an annual maximum of $ for thecurrent calendar year to the New York State Medical Assistance Program upon written noticethat the program has paid health care expenses on behalf of the child(ren) for costs incurredduring the current calendar year. G The parties further agree that the non-custodial parent herein pay as part ofthe cash medical support obligation up to an annual maximum of $ for thecalendar year commencing January 1, and for every year thereafter to the New York StateMedical Assistance Program upon written notice that the Medicaid program has paid health careexpenses on behalf of the child(ren).G The parties further agree that the non-custodial parent herein shall pay the
Form 4-SM-1 Page 6amount of $ , representing his/her share of premiums and/or costs incurred by theNew York State Medical Assistance Program for the period of time from to the date of this order, which amount shall be support arrears/past due support;[Applicable to all children receiving Medicaid coverage]:iv. The parties agree that in the event that the child(ren) cease(s) to be enrolled in theNew York State Medical Assistance Program, the non-custodial parent’s obligation to pay his/hershare of managed care coverage premiums and/or fee-for-service reimbursement shall terminateas of the date the child(ren) is/are no longer enrolled in Medicaid;r. G The parties agree that the legally responsible relative shall immediately notify the[check applicable box]: G other party (non-IV-D cases) G Support Collection Unit (IV-D cases) of any change in health insurance benefits, including any termination of benefits, change in thehealth insurance benefit carrier or premium, or extent and availability of existing or new benefits;s. The parties agree that [specify name]: shall execute anddeliver to [specify name]: any forms, documents, or instruments toassure timely payment of ay health insurance claim for said defendant(s); t. The parties agree that upon a finding that the above-named legally-responsiblerelative(s) willfully failed to obtain health insurance benefits in violation of this stipulation, such relative(s) will be presumptively liable for all health care expenses incurred on behalf of theabove-named defendant(s) from the first date such dependent(s) Q was Q were eligible to beenrolled to receive health insurance benefits after the issuance of such order or executiondirecting the acquisition of such coverage;u. The parties agree that [specify]: the legally-responsible relative(s) herein, shall pay (his)(her) pro rata share of future reasonable healthexpenses of the child(ren) not covered by insurance by [check applicable box]: G directpayments to the health care provider G other [specify]: ; v. The parties agree that if health insurance benefits for the above-named child(ren) notavailable at the 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 andwithout regard to seasonal enrollment restrictions and shall maintain such benefits so long asthey remain available; and it is furtherw. The parties agree that [specify]: , thenon-custodial parent, shall pay the sum of $ as Q his Q her proportionate shareof reasonable child care expenses, to be paid as follows: x. The parties agree that , the non-custodial parent, shall pay the sum of $ as educationalexpenses by G direct payment to the educational provider G other [specify]:
Form 4-SM-1 Page 7y. The parties agree 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/orGmaintain the following existing G life and/or G accident insurance policy in theamount of [specify]: and/orGassign 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 irrevocablebeneficiary during the following time period [specify]: .The obligation to provide such insurance shall cease upon the termination of the duty of[specify party]: to provide support for each child;. and it isfurtherG The parties agree that the support obligor, the non-custodial parent, is directed to: 2G seek employmentG participate in job training, employment counseling, or other programs designed to lead toemployment [specify program]:[IV-D Cases]: The parties agree that when the person or family to whom familyassistance is being paid no longer receives family assistance, support payments shall continue tobe made to the Support Collection Unit, unless such person or family requests otherwise; and[REQUIRED] The parties agree that a copy of this order shall be provided promptly by[specify]: G Support Collection Unit [IV-D cases] GOther [non-IV-D cases; specify]: to the New York State Case Registry of Child Support Orders established pursuant to Section111-b(4-a) of the Social Services Law. This stipulation has been read by each of the parties, and signed by each of them on the day of , , before Support Magistrate , part , Family Court, County._____________________________________________________Signature - mother Signature - father Inapplicable where support obligor is receiving SSI or social security disability benefits. See FCA §437-a. 2
Form 4-SM-1 Page 8______________________________________________________Print or Type Name Print or Type Name______________________________________________________Signature of Attorney, if any Signature of Attorney, if any_________________________________________________________Attorney’s Name ( Print or Type)Attorney’s Name (Print or Type)__________________________________________________________________________________________________________________ Attorney’s Address and Telephone Attorney’s and Telephone NumberNumberDated: , .________________________________Support MagistrateNOTE: (1) THIS ORDER OF CHILD SUPPORT SHALL BE ADJUSTED BY THEAPPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THESUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTERTHIS ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUESTOF ANY 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 EVIDENCE WHICHTHE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER INACCORDANCE 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 SUCH ORDER 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 FAMILYCOURT ACT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL
Form 4-SM-1 Page 9BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THETERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTEDOCCURRING OR AFTER THE EFFECTIVE DATE OF THE ORDER, REGARDLESS OFWHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED 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 SHOWING OF:(I) A SUBSTANTIAL CHANGE IN CIRCUMSTANCES; OR (II) THAT THREE YEARSHAVE PASSED SINCE THE ORDER WAS ENTERED, LAST MODIFIED OR ADJUSTED;OR (III) THERE HAS BEEN A CHANGE IN EITHER PARTY'S GROSS INCOME BYFIFTEEN PERCENT OR MORE SINCE THE ORDER WAS ENTERED, LAST MODIFIED,OR ADJUSTED; HOWEVER, IF THE PARTIES HAVE SPECIFICALLY OPTED OUT OFSUBPARAGRAPH (II) OR (III) OF THIS PARAGRAPH IN A VALIDLY EXECUTEDAGREEMENT OR STIPULATION, THEN THAT BASIS TO SEEK MODIFICATION DOESNOT APPLY.
