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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 sup-port 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

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.

__________________________________________________________________________________

Signature of applicant

______________________________

Date

NOTARY

State of ____________________________________________________ County of ______________________________________________________

On the _______________ day of ______________________________________ in the year _________________ before me, the above signed,

personally appeared __________________________________ , personally known to me on the basis 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 signature ____________________________________________________________________

Notary ID Number: _______________________________

Notary Stamp

Expiration Date __________ / __________ / __________

Month

Day

Year

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

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

Dental Hygiene Anesthesia Form 1, Page 2 of 2, Rev. 10/15

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