Family Court Of The State Of New York County Of (Page 2 of 9) in pdf

Form 4-SM-3 page 2

G did not file a net worth statement or financial disclosure affidavit

and G did G did not have good cause for not filing.

b. Respondent: G filed a net worth statement or financial disclosure affidavit.

G did not file a net worth statement or financial disclosure affidavit

and G did G did not have good cause for not filing.

6. The basic child support obligation for support of the following child(ren) [specify

is $ ______ G weekly G every

name(s)]:

two weeks G monthly Gtwice per month G quarterly.

7. The mother is the G custodial Gnon-custodial parent, whose pro rata share of the basic

child support obligation is [specify]: $ ______ G weekly G every two weeks G monthly Gtwice per

month G quarterly.

8. The father is the G custodial Gnon-custodial parent, whose pro rata share of the basic

child support obligation is [specify]: $ ______ G weekly G every two weeks G monthly Gtwice per

month G quarterly.

9. G a. Petitioner has available health insurance coverage under [specify plan]:

This plan: G covers the following children [specify]:

with the following contribution or premium paid by Petitioner

[specify]: $ ______ G weekly G every two weeks G monthly

Gtwice per month G quarterly.

G can be extended to cover the following children [specify]:

with the following contribution or premium paid by Petitioner

[specify]: $ ______ G weekly G every two weeks G monthly

Gtwice per month G quarterly.

This plan contains the following benefits: G medical G major medical/hospital

G dental G optical G prescription drugs G other [specify]:

G b. Respondent has available health insurance coverage under [specify plan]:

This plan: G covers the following children [specify]:

with the following contribution or premium paid by Petitioner

[specify]: $ ______ G weekly G every two weeks G monthly

Gtwice per month G quarterly.

G can be extended to cover the following children [specify]:

with the following contribution or premium paid by Petitioner

[specify]: $ ______ G weekly G every two weeks G monthly

Gtwice per month G quarterly.

This plan contains the following benefits: G medical G major medical/hospital

G dental G optical G prescription drugs G other [specify]:

G c. Neither Petitioner nor Respondent have available health insurance coverage.

Family Court Of The State Of New York County Of Page 2