Child Support Form (Appendix To A License Application) - Putnam County printable pdf download

Child Support Form (Appendix To A License Application) - Putnam County

New York State Department of Labor

Appendix to a License Application

The child support obligations (New York State General Obligations Law Title 5

section 3-503) do not apply to corporations.

Complete, sign and date this form if you are applying for a license or license renewal.

Applicant

a. Name:

b. Social Security Number:

d. The type of license requested:

c. Title

e. Business Name (if applicable):

Certification

Yes

Are you under an obligation to pay child support? If yes, complete items 1 - 4.

Yes

1. I am making payments in accordance with a plan agreed upon by the parties.

Yes

2. I am four months or more behind in the payment of child support.

Yes

3. My child support obligation is the subject of a pending court proceeding.

Yes

4. I am receiving public assistance or supplemental security income.

If you are four months or more behind in child support or have failed to comply with a summons,

subpoena or warrant relating to a paternity or child support proceeding you may be subject to

suspension of your business, professional and/or driver licenses.

Affirmation

I acknowledge that giving false information is a crime and may result in this license/certificate being revoked.

Signature: ____________________________________________ Date: ___________________________

GO 1 (2-10)

Child Support Form (Appendix To A License Application) - Putnam County