Gc/bc Form 103 Schedule D - Individual Statement (Page 2 of 2) in pdf

13(a) Are you under any obligation to pay child support? ____ yes ____no

13(b) If you are under such obligation, do you meet on of the four requirements listed in the Child Support Law

Section below? ____ yes ____ no

If yes, give details on a separate sheet of paper.

Child Support Law: The NYS General Obligations law requires that every applicant or professional license, permit,

or registration or any other renewal thereof, must file a written statement that, as of the date of the filing, he or she

is or is not under an obligation to pay child support. Individuals who are four months or more in arrears in child

support may be subject to suspension of their business, professional and/or diver’s licenses. The intentional

submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support

obligation is punishable pursuant to Section 175.35 of the NYS Penal Law. You must answer whether or not you are under

an obligation to pay child support; if you are under such an obligation and you cannot attest to one of the four

requirements listed below, the registration of your license may only be renewed for a period of six months. If at the

end of that period, you are still unable to attest to meeting one of the four requirements, your license may be

suspended following due process. If you are under an obligation to pay child support, you must be able to attest to

one of the following four requirements: 1) you are not four or more months in arrears in the payment of child

support; 2) you are making payments by income execution or by a court agreed payment or repayment plan or by a

plan agreed to by the parties; 3) your child support obligation is the subject of a pending court proceedings; or 4)

you are receiving public assistance or supplemental security income.

14.

State the total amount of monies invested in your supply business: $____________________________________

15.

Indicate where the source of invested monies came from (ex. bank accounts, loans, mutual funds, etc.)

Source

Amount

Source

Amount

_________________ $_________________

__________________

$___________________

_________________ $_________________

__________________

$___________________

_________________ $_________________

__________________

$___________________

16.

Will you take an active part in the day-to-day operation of the business? ____ yes ____ no

If yes, on a separate sheet of paper indicate all duties you will be performing.

__________________________________________________________________________________________________

_______________________________________ being duly sworn and says that he/she is the person above names, that

(Print Name of Applicant)

He/she has read the foregoing statement and the answer therein noted, and that such answers are true and that he/she has

personally affixed his/her signature to this affidavit.

Sworn to before me on this ___________ day of _________________, 20______

_____________________________________________________

NOTARY STAMP

(Signature of Applicant)

_____________________________________________________

(Signature of Notary Public)

STAPLE COLOR PHOTO

HERE

Page 2 of 2

Form 103 (Rev. 10/2015)

Gc/bc Form 103 Schedule D - Individual Statement Page 2

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