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Case Reg (NYS Unified Court System Division of Technology)

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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.
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.)
The order expires on: the youngest child’s 21
st
birthday, or ________________ (MM/DD/YYY)
FAMILY VIOLENCE INQUIRY
Has a Temporary or Final Order of Protection been granted on behalf of either party? Yes No Do not know
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
Rev. 08/2012
Print Form
INSTRUCTIONS FOR COMPLETING THE
NEW YORK STATE CASE REGISTRY FILING FORM
0
Field Instruction
Name of Court Enter either "Supreme Court" or "Family Court."
County Name Enter the name of the County entering the support order.
Index/Docket Number
Enter the Index Number (Supreme Court) or Docket Number (Family Court).
Child Support Payor
Enter, at a minimum, the first and last name of the child support payor. If there is
more than one child support payor, please use a separate form to record the
information for the additional child support payor.
Social Security Number
(Payor)
Enter the full Social Security number of the child support payor. Enter "None" if the
court record indicates that the individual has not been issued a Social Security
number. Enter "Not on Record" if the Social Security number is not in the court
record. Redaction is not allowed. An entry of "N/A," "not available," or "not
applicable" is not allowed.
Date of Birth (Payor) Enter the date of birth of the child support payor in the format MM/DD/YYYY.
Child Support Payee
Enter, at a minimum, the first and last name of the child support payee. An entry of
"guardian" or other title is not allowed. If there is more than one child support payee,
please use a separate form to record the information for the additional child support
payee.
Social Security Number
(Payee)
Enter the full Social Security number of the child support payee. Enter "None" if the
court record indicates that the individual has not been issued a Social Security
number. Enter "Not on Record" if the Social Security number is not in the court
record. Redaction is not allowed. An entry of "N/A," "not available," or "not
applicable" is not allowed.
Date of Birth (Payee) Enter the date of birth of the child support payee in the format MM/DD/YYYY.
Child Name
Enter, at a minimum, the first and last name of each child covered by the order. If
more than three (3) children are covered by the order, please use a separate form to
record the information for the additional children.
Social Security Number
(Child)
Enter the full Social Security number of each child covered by the order. Enter
"None" ir the court record indicates that the individual has not been issued a Social
Security number. Enter "Not on Record" if the Social Security number is not in the
court record. Redaction is not allowed. An entry of "N/A," "not available," or "not
applicable" is not allowed.
Date of Birth (Child)
Enter the date of birth of each child covered by the order in the format
MM/DD/YYYY.
Order Expiration
Provide the expiration date for the child support order. You may either check the first
box to indicate that the order expires on the youngest child's 21
st
birthday, or you may
check the second box and provide any alternative date provided for under the terms of
the support order. Provide the expiration date in the format MM/DD/YYYY.
Family Violence
Inquiry
Check the appropriate box to indicate whether a Temporary or Final Order of
Protection has been granted on behalf of either party to the order. If "yes" is selected,
check the appropriate box to indicate which party has been granted the Order of
Protection.
Check the appropriate box to indicate whether a request for confidentiality of address
has been granted on behalf of either party. If "yes" is selected, check the appropriate
box to indicate the party on whose behalf the confidentiality authorization was made.
Rev. 08/2012
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Case Reg (NYS Unified Court System Division of Technology)

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Completed 18 July 2020

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