New York Family Court

Form 4-11a: Support - Order Extending, Modifying or Terminating Order of Support

F.C.A. §§ 413, 440, 442-447, 449, 451, 461, 466, 467

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

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.

IF THIS ORDER WAS ENTERED BY A JUDGE, THE ORDER MAY BE APPEALED PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT...

The petition having been filed in this Court seeking to terminate extend modify a judgment order, dated , granting support made by the Supreme Court of the State of New York, County , entitled , Index No. ;

Family Court of County Other court: ;

It appearing that under the terms of the judgment order the Supreme Court has has not retained exclusive jurisdiction to modify the judgment order;

It appearing that the Court is a court of competent jurisdiction outside the State of New York;

It appearing that [check applicable box(es)]:

there has been a substantial change of circumstances since the entry of the judgment order;

there has been a change in excess of 15% in income since the entry of the judgment order...

three years have elapsed since the entry of the judgment order...

no grounds exist for seeking a modification of child support;

Child Support Findings

The basic child support obligation for support of the following child(ren) is $ weekly, every two weeks, monthly, twice per month, quarterly:

NAME / DATE OF BIRTH / SOC. SEC. # (last 4 digits) / AMOUNT

The mother is the custodial non-custodial parent, whose pro rata share of the basic child support obligation is $ ;

The father is the custodial non-custodial parent, whose pro rata share of the basic child obligation is $ ;

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

Upon consideration of the factors specified, the non-custodial parent's pro rata share is unjust inappropriate;

Parties stipulated to child support for the child(ren) payable by in the amount of $

Employer information (modification only):

Order Disposition

ORDERED that the petition for modification is DENIED.

ORDERED that the judgment order is TERMINATED;

ORDERED that the judgment order is CONTINUED until further order of this Court;

ORDERED that the judgment order is MODIFIED in the following respects:

Arrears in the amount of $ are annulled/reduced/fixed at the full amount of $;

Judgment be entered in favor of the Petitioner against the Respondent in the amount of $ plus interest from in the amount of $ plus costs and disbursements in the amount of $ for a total sum of $;

Support Payment Terms

Respondent/Petitioner responsible for support from filing date to this order less amount already paid of $.

Shall pay the sum of $ as follows: $ immediately, $ weekly, every two weeks, twice per monthly, quarterly.

Payable to: Petitioner by cash, check or money order Respondent 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 IV-D cases: Payable by check or money order made payable to and mailed to the NYS Child Support Processing Center

This order shall be enforceable by immediate income deduction order;

Court shall NOT issue an immediate income execution due to good cause;

Respondent/custodial parent shall immediately notify the Support Collection Unit of changes in contact, SSN, employer, and insurance information;

Health Insurance

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

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

Name:

Health insurance coverage is available to both parents as follows:

No legally-responsible relative has coverage; child(ren) may be eligible for Child Health Plus or Medical Assistance.

No legally-responsible relative has coverage; child(ren) are currently enrolled in Medical Assistance.

Legally-responsible relative(s):

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

enroll eligible dependent(s) immediately and maintain such coverage;

Pro rata share of health insurance cost/premiums:

Mother: ; Father:

Each parent shall pay premiums/contribution in proportion to income;

Pro-rating payment would be unjust or inappropriate:

Managed care premium payment of $ per .

Fee-for-service payment up to annual maximum of $.

Pay amount of $ as support arrears/past due support.

Legally responsible relative shall immediately notify other party/Support Collection Unit of changes in health insurance benefits;

[Specify name] shall execute and deliver forms to assure timely payment of health insurance claims:

Specify name:

If health insurance benefits are not available now but become available later, relative(s) shall enroll eligible dependent(s) immediately;

Medical support enforcement shall not be issued unless health insurance becomes available;

Additional Support Obligations

Non-custodial parent shall pay reasonable child care expenses of $;

Non-custodial parent shall pay educational expenses of $;

Purchase and maintain life and/or accident insurance policy in the amount of $;

Maintain existing life and/or accident insurance policy in the amount of $;

Assign beneficiaries to existing policy/policies:

Support obligor is directed to seek employment;

Participate in job training, employment counseling, or other employment programs:

When family assistance ends, support payments shall continue to be made to the Support Collection Unit unless otherwise requested;

Copy of this order to the New York State Case Registry of Child Support Orders shall be provided by Support Collection Unit / Clerk of Court;

Other ordered provisions:

Information Concerning Cost of Living Adjustments and Modifications

(1) This order of child support shall be adjusted by 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.

(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...

(3) Where any party fails to provide and update current address, the support obligation amount shall become due and owing on the date the first payment is due under the terms of the order.

(4) Each party has a right to seek modification upon substantial change in circumstances, after three years, or upon a 15% gross income change, subject to opt-out agreements.