Fill and Sign the Form 5 6a

F.C.A. §542; Art.5-B Form 5-6a (Paternity-Temporary Order of Support on Default) 5/2015 At a term of the Family Court of the State of New York, held in and for the County of , at New York on , . P R E S E N T: Hon. Judge/Support Magistrate ............................................................................ In the Matter of a Paternity Proceeding Docket No. (Commissioner of Social Services, Assignee) on behalf of ,Assignor) TEMPORARY ORDER Petitioner, OF SUPPORT ON S.S.#: xxxx-xx- DEFAULT -against- Respondent. S.S.#: xxxx-xx- ............................................................................ NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS FOR CONTEMPT OF COURT OR PROSECUTION FOR CRIMINAL NON-SUPPORT. YOUR FAILURE TO OBEY THIS ORDER MAY RESULT IN 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. The above-named Petitioner having filed a petition, sworn to on , , alleging that the above-named QAssignor Q Respondent is the father of a Q male Q female child [insert child’s name and LAST four digits of the social security number]: born out of wedlock to on , , and that Q the mother and/or child is or is likely to become a public charge; and The Respondent having appeared before this Court to answer the petition, having been advised by the Court of the right to counsel and having been ordered to show cause why a declaration of paternity, order of support and other relief requested in the petition should not be made; and the Respondent having denied the allegations of the petition; and The Court having ordered the administration and analysis of a genetic marker test pursuant to Section(s) Q418 Q532 QArt.5-B of the Family Court Act; and Form 5-6a Page 2 Q The Respondent having willfully failed to appear before this Court subsequent to the administration and analysis of such test, which does not exclude the Q Respondent Q Assignor as being the father of the child, it is therefore Q The Respondent having willfully failed to comply with the order directing submission to such test, and having also willfully failed to appear before this court on the adjourned date, it is therefore Q ORDERED that commencing on [specify]: the above-named Respondent, upon notice of this order, pay or cause to be paid the sum of $ G weekly G every two weeks G monthly Gtwice per month G quarterly 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 NYS Child Support Processing Center, P. O. Box 15365, Albany, NY 12212-5365. The county name 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 Child Support Processing Center, PO Box 15363, Albany, NY 12212-5363. The county name and New York Case Identifier number for the matter must be included with the payment for identification purposes; The name, address and telephone number of Respondent’s current employer(s), are:NAME ADDRESS TELEPHONE and it is further [IV-D cases only]: G ORDERED that the Respondent, custodial parent and any other individual parties immediately notify the Support Collection Unit of any changes in the following information: residential and mailing addresses, social security number, telephone number, 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 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, dental, optical, prescription drug and health 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 Benefits Form 5-6a Page 3 G 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, G 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)]: 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 remains available; 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 as 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 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 and prescription drug needs of the dependents named above and any other health care services or benefits 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 benefit or option not otherwise provided under the group health plan except to the extent necessary 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 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 G IT 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 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 Q custodial Qnon-custodial parent, whose pro rata share of the cost 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 or premiums 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 proportion as each of their incomes are to the combined parental income as cited above; OR G Upon consideration of the following factors [specify]: pro-rating the payment would be unjust or inappropriate for the following reasons [specify]: Form 5-6a Page 4 and, therefore, the payments shall be allocated as follows [specify]: ; and it is further OR G [Where the child(ren) are recipients of managed care coverage under the New York State Medical Assistance Program] ORDERED that , the non-custodial parent herein, shall pay the amount of $ per toward to the managed care premium under the New York State Medical Assistance Program; G [Where the child(ren) are recipients of fee-for-service coverage under the New York State Medical Assistance Program] ORDERED that , the non-custodial parent herein, shall pay up to an annual maximum of $ for the current calendar year to the New York State Medical Assistance Program upon written notice that the program has paid health care 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 State Medical Assistance Program] ORDERED that , the non-custodial parent herein, 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 New York State Medical Assistance Program upon written notice that the Medicaid program has paid health care expenses on behalf of the child(ren). G ORDERED that , the non-custodial parent herein, shall pay the amount of $ , representing his/her share of premiums and/or costs incurred by the New 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; G 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 [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 the health insurance benefit carrier 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, documents, or instruments to assure timely payment of any health insurance claim for the child(ren); 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 [check applicable box(es)]: G this order G the medical execution G 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) from the first date such dependent(s) Q was Q were eligible to be enrolled to receive health insurance benefits Form 5-6a Page 5 after the issuance of such order or execution directing the acquisition of such coverage; and it is further ORDERED that [specify]: 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 [check applicable box]: G direct payments to the health care provider G other [specify]: ; and it is further ORDERED that, if health insurance benefits for the above-named child(ren) not available 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 and without regard to seasonal 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 an execution for medical support enforcement shall not be issued by the support collection unit unless a subsequent determination is made by the Court that such health insurance benefits are available; and it isfurther G ORDERED that , the non-custodial parent herein, pay the sum of $ as Q his Q her proportionate share of reasonable child care expenses, to be paid as follows: ; and it is further G ORDERED that , the non-custodial parent herein, pay the sum of $ as educational expenses by G direct payment to the educational provider G other [specify]: ; and it is further G ORDERED that [specify party or parties; check applicable box(es): G purchase and maintain G life and/or G accident insurance policy in the amount of [specify]: and/or G maintain the following existing G life and/or G accident insurance policy in the amount of [specify]: and/or G assign 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 beneficiary 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 is further [IV-D Cases]: G 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; and it is further Form 5-6a Page 6 G ORDERED that the support obligor, the non-custodial parent, is directed to: 1 G seek employment G participate in job training, employment counseling, or other programs designed to lead to employment [specify program]: [JUDICIAL ORDERS ONLY] G ORDERED that Respondent shall have the following rights of visitation with respect to the child(ren)[specify]: ORDERED that this order shall be enforceable pursuant to Section 5241 or 5242 of the Civil Practice Law and Rules, or in any other manner provided by law; and it is further ORDERED that this matter is adjourned to [specify date]: for further proceedings; and [REQUIRED] IT IS FURTHER ORDERED that a copy of this order be provided promptly 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 established pursuant to Section 111-b(4-a) of the Social Services Law; and it is further ORDERED that [specify]: IF THE 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. Dated: , . ENTER ______________________________________ (Judge of the Family Court)(Support Magistrate) Check applicable box:  Order mailed on [specify date(s) and to whom mailed]:_______________________  Order received in court on [specify date(s) and to whom given]:________________ 1 Inapplicable where support obligor is receiving SSI or social security disability benefits. See FCA §437-a.