Fill and Sign the Note Personal Information Form 4 55 1d

Page 1 F.C.A. §§ 440, 442 -447, 449, 451, 461 Form 4 -11 466, 467, S.S.L. § 111 -g (Support -Petition for [NOTE : Personal Information Form 4 -5/5 -1d, Modification) containing social security numbers of parties and 10/2016 dependents, must be filed with this Petition] FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .......................................... .......................................... In the Matter of a Proceeding for Support Under Article 4 of the Family Court Act Docket No. (Commissioner of Social Services, Assignee, on behalf of , Assignor) PETITION FOR MODIFICATION OF AN ORDER OF SUPPORT MADE BY Petitioner, ☐ FAMILY COURT ☐ ANOTHER COURT (Assignor) -against - Respondent. ....................................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully shows that: 1. a. I am [che ck box]: □ an individual and am related to the child(ren) as follows [specify]: and I reside at [specify]: 1 □ assignee agency, which has its place of business at [specify]: b. Respondent resides at [specify]: 2 . 2. a. I was the □ petitioner □ respondent in an action instituted in the □ Supreme Court of the State of New York, [specify county]: County □ Other Court [specify other court]: Court of b. The action was named [specify] : , Index/Docket No. [specify ]: Respondent was □ petitioner □ respondent in the action. 1 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154 -b; Form 21 (available at www.nycourts.gov). 2 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154 -b; Form 21 (available at www.nycourts.gov). Page 2 3. a. A □ judgment □ order, dated , was entered in the action dir ecting t he □ Respondent □ Petitioner to [specif y terms]: . A true copy of the □ judgment □ order is attached and made a part of this Petition. b. An order of support dated , was entered directing the □ Respondent □ Petitioner to [specify terms]: . A true copy of the □ judgment □ order is attached and made a part of this Petition. 4. The names, addresses and dates of birth of all children affected by this o rder are: CHILD’S NAME ADDRESS 3 DATE OF BIRTH 5. a. Under the terms of the □ judgment □ order , the □ Supreme Court □ Other Court >VSHFLI\@KDVQRWUHWDLQHGH[FOXVLYHMXULVGLFWLRQWRPRGLI\WKH
‘ judgment □ order. b. [Check if applicable]: □ The other Court is a court of competent jurisdiction outside the State of New York. 6. (Upon information and belief) I have standing to seek a modification of child support because, since the entry of the □ judgment □ order, [check applicable box]: □ there has been a substantial change of circumstances in that [specify]: 4 3 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154 -b; Form 21 (available at www.nycourts.gov). 4 If incarceration is the basis for alleging substantial change in circumstances, so state and indicate whether or not the incarceration resulted from a charge and/or conviction for nonpayment of child support or an offense against the custodial parent or chil d who is the subject of the child support order. See Family Court Act §451(2)(a); Domestic Relations Law §236B(9)(b)(2)(i). Page 3 □ Unless the parties have specifically agreed otherwise in a validly executed agreement or stip ulation, three years have passed since the order was entered, last modified or adjusted. [ NOTE : This ground only applies to original or modified support orders entered on or after October 13, 2010]. □ Unless the parties have specifically agreed otherwis e in a validly executed agreement or stipulation, 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. [ NOTE : This ground only applies to original or modified support orde rs entered on or after October 13, 2010]. The basis for this allegation is as follows [specify]: 7. The □ judgment □ order should be modified as follows [specify]: . 8. [Delete if inapplicable]: I did not make an applicati on earlier for relief from the □ judgment □order directing payment prior to the accrual of arrears because (s)[specify reason(s)]: 9. [Applicable to individual petitioners; if agency, skip to ¶10]: check a box only if applicable]: I am hereby applying for child support services from the Support Collection Unit (the IV -D program pursuant to Title 6 -A of the Social Services Law) through the filing of this Petition, unless: □ I have already applied for child support services from the Support Collection Unit (the IV -D program pursuant to Title 6 -A of the Social Services Law) □ I do not need to apply now because I have continued to receive child support services after the publ ic assistance or care case, or foster care case, for my family has closed. □ I do not wish to apply for child support services. □ I am not eligible to apply for child support services because I am petitioning for spousal support only. 10. No previous a pplication has been made to any judge or court, including a Native American tribunal, or is presently pending before any judge or court, for the relief requested in this petition (except WHEREFORE, I respectfully request that the □judgment □ order of the □ Supreme Court □ Other Court [specify]: , dated , be modified as set forth above and for such other relief as the Court may deem just and proper. NOTE: (1) COURT ORDER OF SUPPORT RESULTING FROM A PROCEEDING COMMENCED BY THIS APPLICATION (PETITION) 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 SUCH ORDER IS ISSUED, LAST MODIFIED OR LAST ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH (2) BELOW. SUCH COST OF Page 4 LIVING ADJUSTMENT SHALL BE ON NOTICE TO BOTH PARTIES WHO, IF THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHA LL HAVE THE RIGHT TO BE HEARD BY THE COURT AND TO PRESENT EVIDENCE WHICH THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE WITH SECTION FOUR HUNDRED THIRTEEN OF THE FAMILY COURT ACT, KNOWN AS THE CHILD SUPPORT STANDARDS ACT. (2) A PARTY SEEKING SUPPORT FOR ANY CHILD(REN) RECEIVING FAMILY ASSISTANCE SHALL HAVE A 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 L AST ADJUSTED BY THE SUPPORT COLLECTION UNIT, WITHOUT FURTHER APPLICATION BY ANY PARTY. ALL PARTIES WILL RECEIVE A COPY OF THE ADJUSTED ORDER. (3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT COLLECTION UNIT WITH A CURRENT A DDRESS, AS REQUIRED BY SECTION FOUR HUNDRED FORTY -THREE OF THE FAMILY COURT ACT, TO WHICH AN ADJUSTED ORDER CAN BE SENT, 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 ON OR AFTER THE EFFECTIVE DATE OF THE ADJUSTED ORDER, REGARDLESS OF WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER . _____________________ ______ _______ _ Dat ed: Petitioner ___________________________ ______ __ Print or type name ____________________________ _______ Signature of Attorney, if any ____________________________ _______ Attorney’s Name (Print or Type) ____________________________ _______ ____________________________ _______ Attorney’s Address and Telephone Number