Form 4-21 - Order To Licensing Entity
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2F.C.A. §§ 458-a,458-b, 458-c
Form 4-21
548-a, 548-b, Art. 5-b
(Order to Licensing Entity)
(8/2010)
At a term of the Family Court of the
State of New York, held in and for
the County of_______________________________
at________________________________________,
New York, on _______________________________
.
PRESENT:
HON:_______________________________
Judge/Support Magistrate
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In the Matter of a Proceeding for Support
Docket No.______________
under Article _______ of the Family Court Act
Petitioner,
S.S.#: xxxx-xx-
ORDER TO LICENSING
ENTITY
-against-
Respondent.
S.S.#: xxxx-xx-
DOB
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Respondent’s Address:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G
TO:
(NEW YORK STATE DEPARTMENT OF MOTOR VEHICLES)
G
(OTHER NEW YORK STATE PROFESSIONAL, OCCUPATIONAL, BUSINESS OR
RECREATIONAL , LICENSING ENTITY) [SPECIFY]: ____________________________
An Order of Support under Article ______ of the Family Court Act having been made by this court on
______________________;
[Check applicable box(es)]:
G And this Court having determined, in an order, dated ______________________,____________,
that the Respondent therein has accumulated unpaid child support or combined child and spousal support arrears
equivalent to or in excess of the amount of current support due for a period of four months,)
G And this Court having determined that the Respondent, after having received appropriate notice,
failed to comply with a G summons G subpoena G warrant relating to a G paternity G child support proceeding,)
Now, therefore, it is hereby
ORDERED that the G New York State Department of Motor Vehicles G Other state professional,
business, occupational or recreational, licensing entity [specify]:____________________________________________
commence proceedings to suspend Respondent's G motor vehicle operator's license G professional, business,
1
Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an
unreasonable health or safety risk. See Family Court Act §154-b; General Form 21 (available at
).
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