Form 1cs - Child Support Obligation

ADVERTISEMENT

The University of the State of New York
FORM 1CS
THE STATE EDUCATION DEPARTMENT
Office of the Professions
CHILD SUPPORT
Division of Professional Licensing Services
OBLIGATION
89 Washington Avenue
Albany, NY 12234-1000
ALL APPLICANTS ARE REQUIRED* TO COMPLETE THIS FORM
You must complete this form before we can issue the credential for which you have applied. Individuals who are under an obligation to pay child support
but are not in compliance with the General Obligations Law can be issued a credential for no more than six months to discharge child support obligations
consistent with that law.
Please complete items 1-7 clearly in ink in the boxes below. Be sure to sign and date item 8. Have a Notary Public complete item 9. Return this form to the
address at the end of this form.
*New York State General Obligations Law, Section 3-503
1
2
Birth Date
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Month
Day
Year
Print Name Exactly As It Appears On Your Licensure Application (Form 1)
3
Last
First
Middle
Mailing Address (You must notify the Department promptly of any address or name changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
5
License or Permit No.: _____________________
Not applicable
Profession applying for: ______________________________________
Check only A or B below. If you check B, you must check one of the five statements listed below.
7
I am under an obligation to pay child support and (please check only one of the following)
OR
B
A
I am not under an obligation
to pay child support:
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.
8
I declare and affirm that the above information is true, complete, and correct and I understand that if I am not in compliance with the General
Obligations Law, my legal authority to practice a profession (my registration) will be issued for only 6 months and that practice of a profession
without a current registration constitutes professional misconduct.
Signature: __________________________________________________________________________ Date: ________ / ________ / ________
9
NOTARY CERTIFICATION OF IDENTIFICATION (Certification by Notary Public is required.)
State of __________________________________________ County of _______________________________________
I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this applicant by comparing the
applicant's signature made in my presence on this form with the signature on his/her identifying document. The statements on this document are subscribed
and sworn to before me by the applicant on this __________ day of ____________________, __________.
Notary Public signature _____________________________________________________________________________
Notary ID number __________________________ Expiration date __________ / __________ / __________
Month
Day
Year
Return Directly to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, 89 Washington
Avenue, Albany, NY 12234-1000.
Form 1CS, April 2004

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go