Free Document - New York

REGISTRATION STATEMENT
Responding IV-D Case No. ___________________________________________ Responding Docket No. ______________________________________________ I. Case Summary (Background of this Matter: Court / Administrative Actions) State and County Issuing Order Tribunal Case No. Initiating IV-D Case No. ______________________________ Initiating Docket No. ________________________________

Date of Support Order

Support Amount/Frequency $ II. Mother Information Full Name and Aliases (First, Middle, Last) [

Date of Last Payment

Amount of Arrears $

Period of Computation ________________ thru ______________ Date Date Employer (Name, Street, City, State, Zip)

] Obligor [ ] Obligee Address (Street, City, State, Zip)

SSN: III. Father Information Full Name and Aliases (First, Middle, Last)

[

] Obligor [ ] Obligee Address (Street, City, State, Zip)

Employer (Name, Street, City, State, Zip)

SSN: IV. Caretaker (If Not a Parent) Full Name and Aliases (First, Middle, Last)

Relationship to Child(ren) _____________________________________________________ Address (Street, City, State, Zip)

SSN: V. Additional Case Information This order is registered in the following states:

Description and location of any property not exempt from execution:

Other:

VI. Verification / Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief.

__________________________________ Date

_________________________________________________________________________________ [ ] Party seeking Registration [ ] Records Custodian

__________________________________ Sworn to and Signed Before Me This Date, County/State
Registration Statement

______________________________________________________ Notary Public, Court/Agency Official and Title

____________________ Commission Expires

OMB No. 0970 - 0085

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