ISM Annual Report

F.C.A. §§ 413, 516 Form 5-13 — Order Approving Agreement

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 the Petition for Approval of an Agreement between

Pursuant to section 516 of the Family Court Act

A petition having been duly filed by the above-named Petitioner for the approval of an agreement of support made between said Petitioner and the above-named Respondent, dated with respect to a child who was born about to be born out of wedlock to the Petitioner;

and Notice of such application having been duly given to the Social Services official of the County City Town of wherein the mother resided or the child is found;

The petition having duly come on to be heard before this Court, and the Petitioner and Respondent having consented to the entry of the order approving the agreement, and the aforesaid Social Services official having consented appeared in opposition to the entry of the order approving the agreement;

It appearing that the agreement contains the provisions required by Section 413(1) of the Family Court Act, and that the unrepresented party parties, if any, has have received a copy of the child support standards chart;

It appearing that the amount of child support in the agreement deviates from the basic child support obligation specified in Section 413(1) of the Family Court Act, and the Court having found that the parties' agreement to deviate is approved for the following reasons:

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

Now, therefore, it is hereby ORDERED, that the agreement annexed to the petition is in all respects confirmed and approved; and it is further

[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 residential and mailing addresses, social security number, telephone number, driver's license number, and employer information or health insurance benefits.

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

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

Health insurance coverage would be available to one of the parents or a legally-responsible relative:

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 under Child Health Plus or Medical Assistance.

IT IS THEREFORE ORDERED that legally-responsible relative(s) shall:

continue to maintain health insurance coverage for eligible dependent(s)

enroll the following eligible dependent(s) immediately and maintain such coverage as long as it remains available

[IV-D cases]: the Medical Execution issued by the Support Collection Unit the Medical Execution issued by this Court the Qualified Medical Child Support Order

This Court having found that neither of the parties have health insurance coverage available to cover the child(ren), the custodial parent shall immediately apply to enroll the eligible child(ren) in Child Health Plus and Medical Assistance.

And the Court further finds that:

The mother is the custodial non-custodial parent, whose pro rata share is

The father is the custodial non-custodial parent, whose pro rata share is

Each parent shall pay the premium or family contribution in proportion to income.

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.

ORDERED that if the legally-responsible relative willfully failed to obtain health insurance benefits, such relative(s) will be presumptively liable for all health care expenses incurred.

ORDERED that shall pay his/her pro rata share of future reasonable health expenses by:

direct payments to the health care provider other

ORDERED that if health insurance benefits become available in the future, such relative(s) shall enroll the dependent(s) immediately and maintain such benefits.

ORDERED that the non-custodial parent pay as reasonable child care expenses, to be paid as follows:

Judicial orders only.

ORDERED that the non-custodial parent pay as educational expenses by:

direct payment to the educational provider other

ORDERED that the party or parties purchase and maintain life and/or accident insurance policy.

[IV-D Cases]: support payments shall continue to be made to the Support Collection Unit unless otherwise requested.

ORDERED that Respondent shall have visitation rights with respect to the child(ren):

[REQUIRED] IT IS FURTHER ORDERED that a copy of this order be provided promptly by Support Collection Unit Clerk of Court to the New York State Case Registry of Child Support Orders.

ORDERED that