Electronic Testimony Application Form
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2F.C.A. §§ 433, 531-a, 580-316
Form 4-24/ 5-16/UIFSA-10
12/2015
ELECTRONIC TESTIMONY APPLICATION
AND WAIVER OF PERSONAL APPEARANCE
FAMILY COURT OF THE STATE OF NEW YORK
COUNTY OF
.............................................................................
In the Matter of a Proceeding for Support or Paternity
Under Article 4, 5 or 5-B of the Family Court Act
Petitioner,
S.S.#: xxxx-xx-
-against-
DOCKET NO. _____________
Respondent.
ELECTRONIC TESTIMONY
APPLICATION AND WAIVER OF
S.S.#: xxxx-xx-
PHYSICAL PRESENCE
............................................................................
NOTICE: If you are requesting permission to testify by telephone or by audio-visual or other electronic means,
this form must be submitted IMMEDIATELY to the Court at [specify address and fax number of Court]:
______________________________________________________________________________________________
APPLICANT’S NAME: ________________
APPLICANT’S TELEPHONE: (Home): (
) ___ - ________
1
ADDRESS:
__________________________
(Work): (
) ___ - ________
__________________________
(On court date, I can be reached at): (
) ___ - ________
__________________________
FACSIMILE (Fax):
(
) ___ - _____________________
__________________________
E-MAIL:
______________________________
1. On ________________, I [check applicable box]:
filed the above-captioned petition in the (Family)(Other [specify]:
) Court,
County, State of (New York)(Other [specify]:
). The hearing is scheduled to take place on
[specify date]:
.
received a [check applicable box]:
summons
subpoena
to appear in Family Court,
County, State of New York on [specify date]:
.
2. I request that I be permitted to testify or to give my deposition by [check applicable box]:
telephone
audio-visual means
other electronic means (specify):
.
3. I am making this request for the following reason(s) [check one or more box(es)]:
[Non-New York State Residents only ]: I reside in [specify state or jurisdiction]:
and am making this request for the following reason(s) [specify]: ______________________
____________________________________________________________________________
____________________________________________________________________________
[New York State residents only]:
I reside in
County, New York . This county is not the county where the Family
2
Court is located and is not contiguous to (next to) that county.
1
Specify if address, telephone or other identifying information has been ordered to be kept confidential pursuant to New
York State Domestic Relations Law §§76-h, 254 or Family Court Act §154-b. If your health, safety or liberty or that of your child or
children would be put at risk by disclosure of your address or other identifying information, you may apply for an address
confidentiality order by submitting General Form GF-21 to this Court. This form is available on-line at .
2
For purposes of this application, the five counties (boroughs) of New York City are treated as one county.
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