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15. Child Support Obligation

Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the

date of the filing, she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in arrears

in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support

proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The

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

is punishable under section 175.35 of the Penal Law.

You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with

their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support

obligations.

CHECK ONLY A OR B BELOW. If you check B, you must check one of the five statements listed below it.

I am not under an obligation to pay child support;

I am under an obligation to pay child support and (please check only one of the following)

I am current and am not four months or more in arrears in the payment of child support; or,

I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,

The child support obligation is the subject of a pending court proceeding; or,

I am receiving public assistance or supplemental security income; or,

None of the above four statements apply.

*New York State General Obligations Law, section 3-503

16. Affidavit with Acknowledgement (notarization required)

Applicant

I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I

understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure

and may result in criminal prosecution. This form must be signed and dated in the presence of a Notary Public.

Applicant's Signature

Date

Notary

State of

County of

On the

day of

in the year

before me, the above signed,

personally appeared

, personally known to me or proved to me on the basis

Applicant name

of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed

the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and

correct.

Notary Public's Signature

Notary Stamp

Notary ID number

Expiration Date

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,

NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Clinical Nurse Specialist Form 1, Page 4 of 4, Revised 6/17

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Clinical Nurse Specialist Form 1 - Application For A Clinical Nurse Specialist Certificate - 2016 Page 4

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