Form 425

ORDER UPON SUPPORT AGREEMENT

F.C.A. §§ 413, 416, 424, 425, 439, 439(a), 440, 449; D.R.L. § 240 Form 4-2 (12/2012)

At a term of the Family Court of the State of New York, held in and for the County of , at , New York, on .

PRESENT: Hon.

In the Matter of the Petition for an Order upon an Agreement of Support, between

NOTICE:

YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN INCARCERATION FOR CRIMINAL NON-SUPPORT OR CONTEMPT; SUSPENSION OF YOUR DRIVER’S LICENSE, STATE-ISSUED PROFESSIONAL, TRADE, BUSINESS AND OCCUPATIONAL LICENSES AND RECREATIONAL AND SPORTING LICENSES AND PERMITS; AND IMPOSITION OF REAL OR PERSONAL PROPERTY LIENS.

IF THIS ORDER IS ENTERED BY A JUDGE, PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, WHICHEVER IS EARLIEST.

IF THIS ORDER IS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTEN OBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYS OF THE DATE THE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IF THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER.

A petition having been filed by the above-named Petitioner for the issuance of an order upon an agreement for support made between the Petitioner and the above-named Respondent dated ; and

The petition having been heard by this Court; and the Petitioner having appeared with counsel without counsel and Respondent having appeared with counsel without counsel; and

And the Court finds further that [check applicable box]:

The non-custodial parent's pro rata share of the basic child support obligation is neither unjust nor inappropriate;

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 unjust inappropriate for the following reasons:

And the Court finds further that the parties have voluntarily stipulated to child support for the following child(ren): payable by to in the amount of $ weekly every two weeks monthly twice per month quarterly.

This stipulation has been entered into the record and recites, in compliance with Section 413(1)(h) of the Family Court Act, that:

a. The parties have been advised of the provisions of Section 413(1) of the Family Court Act;

b. The unrepresented party, if any, has received a copy of the child support standards chart promulgated by the Commissioner of the N.Y.S. Office of Temporary and Disability 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(1) presumptively results in the correct amount of child support to be awarded;

d. The basic child support obligation in this case is $ weekly every two weeks monthly twice per month quarterly;

e. The parties' reason(s) for agreeing to child support in an amount different from the basic child support obligation is/are:

The Court approves the parties' agreement to deviate from the basic child support obligation for the following reasons:

The name, address and telephone number of Respondent’s current employer(s) is/are:

NAME ADDRESS TELEPHONE

NOW, therefore, it is hereby ORDERED that the agreement for support annexed to the petition is approved; and it is further ORDERED that pursuant to the annexed agreement for support, the above-named Respondent shall make payments:

weekly, every two weeks, monthly, twice per month, and quarterly as follows:

Name Date of Birth Last 4 Digits of Soc. Sec. # Amount

Total:

ORDERED that, pursuant to Domestic Relations Law §236(B)(1)(a), payments for the support of the spouse shall terminate upon death of the spouse, upon the spouse’s valid or invalid marriage or upon modification in accordance with Domestic Relations Law §236(B)(9) or 248, and it is further

ORDERED and ADJUDGED that the above-named Respondent is responsible for the support so ordered from , the date the petition was filed to the date of this Order, less the amount of $ already paid, and that the Respondent shall pay the sum of $ as follows: $ immediately, $ weekly, $ every two weeks, $ monthly, $ twice per month, $ quarterly;

ORDERED that commencing on the above-named Respondent, upon notice of this Order, pay or cause the above amount(s) to be paid to:

Petitioner by cash, check or money order

Non-IV-D cases: Payable to the Petitioner by check or money order and mailed to the NYS Child Support Processing Center, P.O. Box 15365, Albany, NY 12212-5365.

IV-D cases: Payable by check or money order made payable to and mailed to the NYS Child Support Processing Center, PO Box 15363, Albany, NY 12212-5363.

ORDERED that, pursuant to Family Court Act §440(1)(b)(2), this order shall be enforceable by immediate income deduction order issued in accordance with Section 5242(c) of the Civil Practice Law and Rules; and it is further

ORDERED that, for the following reason(s): constituting good cause pursuant to Family Court Act §440(1)(b), the IV-D cases: Support Collection Unit Non IV-D cases: Court shall NOT ISSUE an immediate income execution;

[IV-D cases only] ORDERED that the Respondent, custodial parent and any other individual parties immediately notify the Support Collection Unit of any changes in address, social security number, telephone number, driver’s license number, and employer information and health insurance benefits.

ORDERED that pursuant to the agreement for support the pay to the sum of $ as and for counsel fees in this proceeding, payable $ weekly every two weeks monthly twice per month quarterly, commencing on .

And the Court having determined that [check applicable box]:

The child(ren) are currently covered by the following health insurance plan: which is maintained by

Health insurance coverage is available to one of the parents or a legally-responsible relative under the following health insurance plan

Health insurance coverage is available to both of the parents as follows:

No legally-responsible relative has health insurance coverage available for the child(ren), but the child(ren) may be eligible for health insurance benefits under the New York “Child Health Plus” program or the New York State Medical Assistance Program, or the publicly funded health insurance program in the State where the custodial parent resides.

No legally-responsible relative has health insurance coverage available for the child(ren), but the child(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)]:

continue to maintain health insurance coverage for the following eligible dependent(s): under the above-named existing plan for as long as it remains available;

enroll the following eligible dependent(s): under the following health insurance plan:

Such coverage shall include all plans covering the health, medical, dental, optical and prescription drug needs of the dependents named and any other health care services or benefits for which the legally-responsible relative is eligible for the benefit of such dependents.

The legally-responsible relative(s) shall assign all insurance reimbursement payments for health care expenses incurred for his her eligible dependent(s) to the provider of such services or the party having actually incurred and satisfied such expenses, as appropriate;

OR

IT IS THEREFORE ORDERED that the custodial parent shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus” program and the New York State Medical Assistance Program or the publicly funded health insurance program in the State where the custodial parent resides.

And the Court further finds that:

The mother is the custodial non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is ;

The father is the custodial non-custodial parent, whose pro rata share of the cost or premiums to obtain or maintain such health insurance coverage is ;

And the Court further finds that [check applicable box];

Each parent shall pay the cost of premiums or family contribution in the same proportion as each of their incomes are to the combined parental income as cited above;

Upon consideration of the following factors:

Therefore, the payments shall be allocated as follows:

OR

[Where the child(ren) are recipients of managed care coverage under the New York State Medical Assistance Program] ORDERED that shall pay the amount of $ per toward the managed care premium.

[Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that shall pay up to an annual maximum of $ for the current calendar year.

[Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that pay as part of the cash medical support obligation up to an annual maximum of $ for the calendar year commencing January 1,

ORDERED that shall pay the amount of $ representing his/her share of premiums and/or costs incurred for the period from to the date of this order.

ORDERED that in the event that the child(ren) cease(s) to be enrolled in the New York State Medical Assistance Program, the non-custodial parent’s obligation to pay his/her share of managed care coverage premiums and/or fee-for-service reimbursement shall terminate as of the date the child(ren) is/are no longer enrolled in Medicaid;

ORDERED that the legally responsible relative immediately notify the other party (non-IV-D cases) Support Collection Unit (IV-D cases) of any change in health insurance benefits.

ORDERED that shall execute and deliver to any forms, notices, documents, or instruments to assure timely payment 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) willfully failed to obtain health insurance benefits in violation of this order the medical execution the qualified medical child support order, such relative(s) will be presumptively liable for all health care expenses incurred on behalf of the above-named defendant(s).

ORDERED that the legally-responsible relative(s) herein, shall pay (his)(her) pro rata share of future reasonable health expenses of the child(ren) not covered by insurance by direct payments to the health care provider other:

ORDERED that, if health insurance benefits for the above-named child(ren) not available at the present time become available in the future, such relative(s) shall enroll the dependent(s) immediately and without regard to seasonal enrollment restrictions and shall maintain such benefits so long as they remain available;

ORDERED that pay the sum of $ as his/her proportionate share of reasonable child care expenses, to be paid as follows:

ORDERED that pay the sum of $ as educational expenses by direct payment to the educational provider other:

ORDERED that purchase and maintain life accident insurance policy in the amount of

maintain the following existing life accident insurance policy in the amount of

assign the following as beneficiary beneficiaries to the following existing insurance policy or policies:

In the case of life insurance, the following shall be designated as irrevocable beneficiaries: during the following time period:

In the case of accident insurance, the insured party shall be designated as irrevocable beneficiary during the following time period:

The obligation to provide such insurance shall cease upon the termination of the duty of to provide support for each child.

ORDERED that the support obligor, the non-custodial parent, is directed to seek employment

participate in job training, employment counseling, or other programs designed to lead to employment:

[IV-D Cases]: ORDERED that when the person or family to whom family assistance is being paid no longer receives family assistance, support payments shall continue to be made to the Support Collection Unit, unless such person or family requests otherwise;

[Judicial orders only] ORDERED that Respondent shall have the following rights of visitation with respect to the child(ren):

[REQUIRED] IT IS FURTHER ORDERED that a copy of this order be provided promptly by Support Collection Unit (IV-D cases) Clerk of Court (non-IV-D cases) to the New York State Case Registry of Child Support Orders established pursuant to Section 111-b(4-a) of the Social Services Law;

ORDERED that

Dated:

Check applicable box:

Order mailed on

Order received in court on

INFORMATION CONCERNING COST OF LIVING ADJUSTMENTS AND MODIFICATIONS

(1) THIS ORDER OF CHILD SUPPORT SHALL BE ADJUSTED BY THE APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER THIS ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW.

(2) A RECIPIENT OF FAMILY ASSISTANCE SHALL HAVE THE CHILD SUPPORT ORDER REVIEWED AND ADJUSTED AT THE DIRECTION OF THE SUPPORT COLLECTION UNIT NO EARLIER THAN TWENTY-FOUR MONTHS AFTER SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED WITHOUT FURTHER APPLICATION OF ANY PARTY.

(3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT ADDRESS TO WHICH AN ADJUSTED ORDER CAN BE SENT AS REQUIRED BY SECTION 443 OF THE FAMILY COURT ACT, THE SUPPORT OBLIGATION AMOUNT CONTAINED THEREIN SHALL BECOME DUE AND OWING ON THE DATE THE FIRST PAYMENT IS DUE UNDER THE TERMS OF THE ORDER OF SUPPORT WHICH WAS REVIEWED AND ADJUSTED OCCURRING OR AFTER THE EFFECTIVE DATE OF THE ORDER, REGARDLESS OF WHETHER 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 RIGHT TO SEEK A MODIFICATION OF THE CHILD SUPPORT ORDER UPON A SHOWING OF: (I) A SUBSTANTIAL CHANGE IN CIRCUMSTANCES; OR (II) THAT THREE YEARS HAVE PASSED SINCE THE ORDER WAS ENTERED, LAST MODIFIED OR ADJUSTED; OR (III) THERE HAS BEEN A CHANGE IN EITHER PARTY'S GROSS INCOME BY FIFTEEN PERCENT OR MORE SINCE THE ORDER WAS ENTERED, LAST MODIFIED, OR ADJUSTED; HOWEVER, IF THE PARTIES HAVE SPECIFICALLY OPTED OUT OF SUBPARAGRAPH (II) OR (III) OF THIS PARAGRAPH IN A VALIDLY EXECUTED AGREEMENT OR STIPULATION, THEN THAT BASIS TO SEEK MODIFICATION DOES NOT APPLY.