Professional Engineering - Application For Licensure And First Registration - The University Of The State Of New York The State Education Department - 2011 Page 3

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Citizenship:

United States

Alien lawfully admitted for permanent residence in the United States

Other immigration status

_____________________________

Citizen of _____________________________________________

(Attach a photocopy of the front and back of your Alien Registration Card)

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 support 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.

STUDENT LOAN DISCLOSURE:

The State Education Department is required* to ask these questions about any student loans made or guaranteed by the New York State Higher