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SAMPLE CHILD SUPPORT ORDER
F.C.A. §§ 413, 416, 433, 438, 4-7 11/2002
439, 440,442-447, 471; Art.5-B,
PRESENT: Family Court, Support Magistrate
In the Matter of a Support Proceeding
Custodial Parent, SSN: XXX-XX-XXXX,
Petitioner,
– against –
Noncustodial Parent, SSN: XXX-XX-XXXX,
Respondent.
NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN INCARCERATION FOR
CRIMINAL NON-SUPPORT OR CONTEMPT. 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.
SPECIFIC WRITTEN OBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30
DAYS OF THE DATE THE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IF
THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER.
The above-named Petitioner having led a petition in this Court on June 22, 2004, alleging that
Noncustodial Parent is chargeable with the support of:
Name Date of Birth
Child’s Name XX/XX/XXXX
Noncustodial Parent having appeared before this Court to answer the petition, having been advised
by the Court of the right to counsel, and to show why an order of support and other relief prayed for
in the petition should not be granted; and Noncustodial Parent having admitted the allegations of
the petition; and the matter having duly come on to be heard before this Court;
NOW, after examination and inquiry into the facts and circumstances of the case and after hearing
the proofs and testimony offered in relation thereto, the Court nds that: Noncustodial Parent is the
Noncustodial party, whose pro rata share of the basic child support obligation is $XX.XX weekly for
the following child:
Name Child Date of Birth Social Security #
And the Court nds further that: The Noncustodial party’s pro rata share of the basic child support
obligation is neither unjust nor inappropriate;
Noncustodial Parent is currently unemployed;
NOW, after examination and inquiry into the facts and circumstances of the case and after hearing
the proofs and testimony offered in relation thereto, it is
ORDERED AND ADJUDGED that effective January 28, 2005, Noncustodial Parent is chargeable
with the support of the following person(s) and is possessed of sufcient means and able to earn
such means to provide the payment of the sum $XX.XX weekly to Custodial Parent by certied
check or money order payable to the Support Collection Unit, such payments to commence on Jan-
uary 28, 2005, for and toward the support of Noncustodial Parent’s children, allocated as follows:
At a term of the Family Court of the
State of New York, held in and for the
County of Richmond, at
100 Richmond Terrace, Staten Island, NY
10301, on October 4, 2004
File #: XXXXX
Docket #: F-XXXXX-XX
CSMS #: XXXXXXXXX
ORDER OF SUPPORT
Family Court
Act laws that
govern the
court hearing
Court address
and the hearing
date
Child support case
and court identifying
information
Form number and date of issue
Parties involved
PART
A
PART
B
PART
C
PART
D
PART
E
Type of order
Filing an
objection
Noncustodial parent’s employment status
Effective
date of
the child
support
order
(Your date
will be
different)
The person who will receive the child support payments
Docket No: F-XXXXX-XX
4-7
Name Social Security # Date of Birth Amount
Children
Child XX/XX/XXXX
Total Child Support: $XX.XX weekly
ORDERED that the payor, custodial party and any other individual parties immediately notify the Sup-
port Collection Unit of any changes in the following information: residential and mailing addresses,
social security number, telephone number, driver’s license number; and name, address and telephone
numbers of the parties’ employers and any change in health insurance benets, including any termina-
tion of benets, change in the health insurance benet carrier or premium, or extent and availability
of existing or new benets; and it is further
ORDERED that this Order shall be enforceable pursuant to Section 5241 or 5242 of the Civil Practice
Law and Rules, or in any other manner provided by law; and it is further
ORDERED that Noncustodial Parent pay additional expenses as follows:
Expense/Payee Payment Payable
Unreimbursed Health Related/
Custodial Parent XX % Via SCU
Child Care/
Custodial Parent XX % Direct
IT IS FURTHER ORDERED that all payments payable through the Support
Collection Unit shall be mailed to: Support Collection Unit, PO Box 15363,
Albany, NY 12212- 5363;
IT IS FURTHER ORDERED that a copy of this order be provided promptly by the Support Collection
Unit to the New York State Case Registry of Child Support Orders established pursuant to Section
111-b(4-a) of the Social Services Law; and it is further ORDERED that this is a $XX per week order of
support from 10/8/04 until it increased on1/28/05.
NOTE: (1) THIS ORDER OF CHILD SUPPORT 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 THIS ORDER IS ISSUED, LAST MODIFIED OR LAST
ADJUSTED, UPON THE REQUEST OF ANY PARTY TO THE ORDER OR PURSUANT TO PARAGRAPH
(2) BELOW. UPON APPLICATION OF A COST OF LIVING ADJUSTMENT AT THE DIRECTION OF THE
SUPPORT COLLECTION UNIT, AN ADJUSTED ORDER SHALL BE SENT TO THE PARTIES WHO, IF
THEY OBJECT TO THE COST OF LIVING ADJUSTMENT, SHALL HAVE THIRTY-FIVE (35) DAYS FROM
THE DATE OF MAILING TO SUBMIT A WRITTEN OBJECTION TO THE COURT INDICATED ON
SUCH ADJUSTED ORDER. UPON RECEIPT OF SUCH WRITTEN OBJECTION, THE COURT SHALL
SCHEDULE A HEARING AT WHICH THE PARTIES MAY BE PRESENT TO OFFER EVIDENCE WHICH
THE COURT WILL CONSIDER IN ADJUSTING THE CHILD SUPPORT ORDER IN ACCORDANCE
WITH THE CHILD SUPPORT STANDARDS ACT.
(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, LAST MODIFIED OR LAST ADJUSTED
WITHOUT FURTHER APPLICATION OF ANY PARTY. ALL PARTIES WILL RECEIVE NOTICE OF AD-
JUSTMENT FINDINGS.
(3) WHERE ANY PARTY FAILS TO PROVIDE, AND UPDATE UPON ANY CHANGE, THE SUPPORT
COLLECTION UNIT WITH A CURRENT ADDRESS TO WHICH AN ADJUSTED ORDER CAN BE
SENT, AS REQUIRED BY SECTION 443 OF THE FAMILY COURT ACT, 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 ORDER REGARDLESS OF
WHETHER OR NOT THE PARTY HAS RECEIVED A COPY OF THE ADJUSTED ORDER.
Dated: October 4, 2004 ENTER
Family Court, Support Magistrate
Check applicable box:
¨ Order mailed on [specify date(s) and to whom mailed]: ___________________
PART
E
cont’d
PART
F
PART
G
Notice to in-
form Agency
of any change
in your
residence,
employment,
etc.
Expenses in addition to the basic
child support amount:
• Medical
• Child care
• Education
Where to send payments until
they come through your job
Summary
of court
ndings
Cost of
Living
Adjustments
(COLA)
Name and
seal of
Support
Magistrate
Sample Child Support Order