Fill and Sign the Ucs 111 Rev12516 Form

UCS-111 (rev:1/25/16) CHILD SUPPORT SUMMARY FORM SUPREME COURT COMPLETE FORM FOR EACH BASIC CHILD SUPPORT OBLIGATION ORDER 1 A. Court:  Supreme B. County: C. Index #: D. Date Action Commenced: / / E. Date Judgment/Order Submitted or Signed: / / F. # Of Children Subject to Child Support Order: G. Annual Gross Income Adjusted for Maintenance: 1. Plaintiff: $ Defendant: $ H. Amount of Child Support Payment: 1. By Plaintiff: $ 2. By Defendant: $ annually annually I. Additional Child Support: (Circle as many as appropriate) By Plaintiff: By Defendant: 1. Medical/Med. Ins. 1. Medical/Med. Ins. 2. Child Care 2. Child Care 3. Education 3. Education 4. Other 4. Other J. Did the court make a finding that the child support award varied from the Child Support Standards Act amount? (Circle one) 1. Yes 2. No K. If answer to “J” was yes, circle court's reason(s): 1. Financial resources of parents/child. 2. Physical/emotional health of child: special needs or aptitudes. 3. Child's expected standard of living had household remained intact. 4. Tax consequences. 5. Non-monetary contribution toward care and well-being of child. 6. Educational needs of either parent. 7. Substantial differences in gross income of parents. 8. Needs of other children of non-custodial parent. 9. Extraordinary visitation expenses of non- custodial parent. 10. Other (specify): L. Maintenance/Spousal Support: (Circle one) 1. None 2. By Plaintiff 3. By Defendant M. Value of Maintenance/Spousal Support: $ annually SUPREME COURT ONLY N. Allocation of Property: % To Plaintiff % To Defendant 1 Defined by FCA 413(2) and DRL §240(1-b)(b)(2): “Child Support” shall mean a sum to be paid pursuant to court order or decree by either or both parents or pursuant to a valid agreement between the parties for care, maintenance and education of any unemancipated child under the age of twenty-one years. UCS-111 (rev. 1/25/16) NEW YORK STATE UNIFIED COURT SYSTEM SUPPORT SUMMARY FORM: FAMILY & SUPREME COURT INSTRUCTION SHEET Prepare one report for each proposed judgment or final order granted pursuant to Article 4 or 5 of the Family Court Act and DRL §240 and §236 B(9)(b) which includes a provision for child support (including modification of order). SUBMIT COMPLETED FORM TO: Office of Court Administration Office of Court Research 25 Beaver Street, Room 975 New York, New York 10004 GENERAL INSTRUCTIONS:  ALL ITEMS MUST BE ANSWERED • If a number or amount in dollars is required and the answer is none, write 0. • If a certain item is not applicable, write NA. • If the information is unknown or not known to the party filling out the form, write UK. • “mm/dd/yy” means “month/day/year”. SPECIAL INSTRUCTIONS FOR PARTICULAR ITEMS: G. Use gross income figures from the last complete calendar year. Include maintenance received from a party spouse as income and deduct maintenance paid to a party spouse from income, but do not include child support. H. If the child support award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26, if semi-monthly, multiply it by 24, if monthly, multiply it by 12. M. If the maintenance award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26; if semi-monthly, multiply it by 24_, if monthly, multiply it by 12. If the maintenance award calls for decreasing or increasing amounts (for example, a certain amount for five years and half that amount for another three years), then provide the average of the awards (total amount for all years divided by the number of years). NOTE: THIS INFORMATION IS CONFIDENTIAL AND WILL BE USED FOR STATISTICAL PURPOSES ONLY. IT WILL NOT BE RETAINED IN THE CASE FILE.