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F.C.A. §§ 413, 516 Form 5-13 (Order - Approval of Agreement) ( 9/2005) At a term of the Family Court of the State of New York, held in and for the County of , at New Yorkon , P R E S E N T: Hon. Judge / Support Magistrate............................................................................................In the Matter of the Petition for Approval Docket No. of an Agreement between Petitioner S.S.# and ORDER APPROVING AGREEMENT Respondent S.S.#Pursuant to section 516 of the Family Court Act ............................................................................................ NOTICE:YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN INCARCERATION FOR CRIMINAL NON-SUPPORT OR CONTEMPT. YOURFAILURE TO OBEY THIS ORDER MAY RESULT IN SUSPENSION OF YOURDRIVER’S LICENSE, STATE-ISSUED PROFESSIONAL, TRADE, BUSINESSAND OCCUPATIONAL LICENSES AND RECREATIONAL AND SPORTINGLICENSES AND PERMITS; AND IMPOSITION OF REAL OR PERSONALPROPERTY LIENS.A petition having been duly filed by the above-named Petitioner for the approval of anagreement of support made between said Petitioner and the above-named Respondent, dated , , with respect to a child [specify name and social security number if childborn]: , who was Q born Q about to be born out of wedlock tothe Petitioner; and Notice of such application having been duly given to , the Social Servicesofficial of the Q County QCity QTown of wherein the mother resided or the childis found; and Form 5-13 Page 2The petition having duly come on to be heard before this Court, and the Petitioner andRespondent having consented to the entry of the order approving the agreement, and the aforesaidSocial Services official having Q consented Q appeared in opposition to the entry of the orderapproving the agreement ; and It appearing that the agreement contains the provisions required by Section 413(1) of the FamilyCourt Act, and that the unrepresented Q party Qparties, if any, Q has Qhave received a copy of thechild support standards chart promulgated by the Commissioner of the N.Y.S. Office of Temporary andDisability Assistance pursuant to Section 111-i of the Social Services Law; and [Check box if applicable]: Q It appearing that the amount of child support in the agreementdeviates from the basic child support obligation specified in Section 413(1) of the Family Court Act,and that the agreement contains the parties' acknowledgment that the basic child support obligation isthe presumptively correct amount of child support, and their reason(s) for not providing for the basicchild support obligation; and the Court having found that the parties' agreement to deviate from thebasic child support obligation is approved for the following reasons: [specify; see Family Court ActSection 413(1)(f)]: The name, address and telephone number of Respondent’s current employer(s) are:NAME ADDRESSTELEPHONENow, therefore, it is hereby ORDERED, that the agreement annexed to the petition is in all respects confirmed andapproved; and it is further[IV-D cases only]: G ORDERED that the Respondent, custodial parent and any otherindividual parties immediately notify the Support Collection Unit of any changes in the followinginformation: residential and mailing addresses, social security number, telephone number, driver’slicense number; and name, address and telephone numbers of the parties’ employers and any change inhealth insurance benefits, including any termination of benefits, change in the health insurance benefitcarrier 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 would be 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]: Form 5-13 Page 3G Health insurance coverage is available to both of the parents as follows: Name Health Insurance Plan Premium or ContributionBenefitsG No legally-responsible relative has health insurance coverage available for the child(ren), but thechild(ren) may be eligible for health insurance benefits under the New York “Child Health Plus”program or 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]: immediatelyand without regard to seasonal enrollment restrictions and maintain such coverage as long as it remainsavailable 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 andprescription drug needs of the dependents named above and any other health care services or benefitsfor 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 nototherwise provided under the group health plan except to the extent necessary to meet the requirementsof Section 1396(g-1) of Title 42 of the United States Code. The legally-responsible relative(s) shallassign all insurance reimbursement payments for health care expenses incurred for Q his Q her eligibledependent(s) to the provider of such services or the party having actually incurred and satisfied suchexpenses, as appropriate;ORG This Court having found that neither of the parties have health insurance coverage availableto cover the child(ren), it is hereby ORDERED that the custodial parent [specify name]: shall immediately apply to enroll the eligible child(ren) in the “Child Health Plus” program (the NYShealth insurance program for children) and the New York State Medical Assistance Program. And the Court further finds that:The mother is the Qcustodial Qnon-custodial parent, whose pro rata share of the cost orpremiums to obtain or maintain such health insurance coverage is ;The father is the Qcustodial Qnon-custodial parent, whose pro rata share of the cost orpremiums to obtain or maintain such health insurance coverage is ;And the Court further finds that [check applicable box]: Form 5-13 Page 4G Each parent shall pay the premium or family contribution in the same proportion aseach of their incomes are to the combined parental income as follows[ specify]: G Upon consideration of the following factors [specify]:pro-rating the payment would be unjust or inappropriate for the following reasons [specify]: Therefore, the payments shall be allocated as follows [specify]: ; and it is furtherORDERED 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 healthinsurance benefits, including any termination of benefits, change in the health insurance benefit carrieror 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, notices, documents, or instruments or assure timelypayment of any health insurance claims for said dependent(s) and it is furtherORDERED that upon a finding that the above-named legally-responsible relative(s) willfullyfailed to obtain health insurance benefits in violation of [check applicable box(es)]: G this orderG the medical execution G the qualified medical child support order, such relative(s) will bepresumptively 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 insurancebenefits after the issuance of such order or execution directing the acquisition of such coverage; and itis furtherORDERED that [specify]: the legally-responsiblerelative(s) herein, shall pay Q his Q her pro rata share of future reasonable health expenses of thechild(ren) not covered by insurance by [check applicable box]: G direct payments to the health careprovider G other [specify]: ; and it is further ORDERED that, if health insurance benefits for the above-named child(ren) not available at thepresent time become available in the future to the legally-responsible relative(s), such relative(s) shallenroll the dependent(s) who are eligible for such benefits immediately and without regard to seasonalenrollment restrictions and shall maintain such benefits so long as they remain available; and it isfurther[Check applicable box(es):G ORDERED that , the non-custodial parentherein, pay the sum of $ as Qhis Q her proportionate share of reasonable child careexpenses, to be paid as follows: ; and it is further Form 5-13 Page 5 Judicial orders only. 1G 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 furtherG ORDERED 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 is further[IV-D Cases}: G ORDERED that when the person or family to whom family assistance isbeing paid, no longer receives family assistance, support payments shall continue to be made to theSupport Collection Unit, unless such person or family requests otherwise;) and it is furtherG ORDERED that Respondent shall have the following rights of visitation with respect tothe child(ren)[specify]:1[REQUIRED] IT IS FURTHER ORDERED that a copy of this order be providedpromptly 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 toSection 111-b(4-a) of the Social Services Law; and it is furtherORDERED that [specify]: Form 5-13 Page 6IF 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 LAW GUARDIAN 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 WRITTENOBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYS OFTHE DATE THE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IFTHE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THEORDER. ENTER (Judge of the Family Court)(Support Magistrate)Dated: , .Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________