New York State Case Registry Filing Form For Use With Child Support Orders And Combined Child And Spousal Support Orders

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IMPORTANT NOTICE TO COURT CLERKS FOR ALL NON-IV-D ORDERS: THIS FORM, RATHER THAN THE CHILD SUPPORT
ORDER, SHOULD BE MAILED BY THE COURT TO THE STATE CASE REGISTRY, P.O. BOX 15101, ALBANY, NY 12212-5101
New York State Case Registry Filing Form *
For Use With Child Support Orders and Combined Child and Spousal Support Orders
Payable To Other Than A Child Support Collection Unit*
*Domestic Relations Law § 240(5) and Family Court Act § 440(5) direct that such orders be promptly provided to the State Case Registry.
The Office of Temporary and Disability Assistance has indicated that the information sought on this form satisfies the requirement to
maintain a record of the order pursuant to Social Services Law § 111-b(4-a)(a)(2) and no order is to be filed unless specifically requested.
Note: Full Social Security Numbers are required on this form. Redaction is not allowed.
Supreme Court
Name of Court:
County Name:
Index Number:
Child Support
Payor:
Social Security #:
Date of Birth:
(first)
(last)
(middle initial)
(Payor)
(Payor)
Child Support
Payee:
Social Security #:
Date of Birth:
(first)
(last)
(middle initial)
(Payee)
(Payee)
Child #1 Name:
Social Security #:
Date of Birth:
(first)
(last)
(middle initial)
(Child #1)
(Child #1)
Child #2 Name:
Social Security #:
Date of Birth:
(first)
(last)
(middle initial)
(Child #2)
(Child #2)
Child #3 Name:
Social Security #:
Date of Birth:
(first)
(last)
(middle initial)
(Child #3)
(Child #3)
(If more children, please use additional form.)
st
The order expires on:
the youngest child’s 21 birthday, or
________________ (MM/DD/YYY)
FAMILY VIOLENCE INQUIRY
Yes
No
Do not know
Has a Temporary or Final Order of Protection been granted on behalf of either party?
If yes, which party:
Payor
Payee
Has a request for confidentiality of address been granted on behalf of either party?
Yes
No
If yes, which party:
Payor
Payee
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