New York Divorce and Child Support Summary Form

The UCS-Divorce and Child Support Summary Form is a form that has to be used in case of a child support order has been made against you. This form has to be completed and submitted for every minor child.

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1 Defined by FCA 413(2) and DRL §240(1-b)(b)(2): “Child Support” shall mean a sum to be paid pursuant to court order or decreeby either or both parents or pursuant to a  valid agreement between the parties for care, maintenance and education of any unemancipated childunder the age of  twenty-one years.UCS-111 (rev:08/11) CHILD SUPPORT SUMMARY FORMSUPREME COURT COMPLETE FORM FOR EACH BASIC CHILD SUPPORT OBLIGATION ORDER1A.    Court:      9 Supreme     B.    County:                                                  C.    Index #:                                                         D.    Date Action Commenced:                  /          /          E.    Date Judgment/Order Submitted or Signed:                   /          /                     F.    # Of Children Subject to Child Support Order:                                        G.    Annual Gross Income:           1.Plaintiff: $                    Defendant: $                               H.   Amount of Child Support Payment:        1.By Plaintiff: $              2.  By Defendant: $          annually    annuallyI.    Additional Child Support:      (Circle as many as appropriate)          By Plaintiff:By Defendant:1.   Medical/Med. Ins.1.   Medical/Med. Ins.   2.   Child Care2.   Child Care3.   Education3.   Education4.   Other4.    OtherJ.   Did the court make a finding that the child                    support award varied from the Child Support               Standards Act amount?    (Circle one)1.  Yes2.  NoK.    If answer to “J” was yes, circle court's reason(s):1.    Financial resources of parents/child.   2.    Physical/emotional health of child:       special needs or aptitudes.3.    Child's expected standard of living had                      household remained intact.4.    Tax consequences.5.    Non-monetary contribution toward care and              well-being of child.6.    Educational needs of either parent.7.    Substantial differences in gross income of                  parents.8.    Needs of other children of non-custodial                    parent.9.    Extraordinary visitation expenses of non-                  custodial parent.  10.  Other  (specify):                                                                                                                                                                                                                                                                                       L.    Maintenance/Spousal Support:(Circle one)        1.  None   2.  By Plaintiff      3.  By Defendant M.    Value of Maintenance/Spousal Support:          $                                     annually        SUPREME COURT ONLYN.    Allocation of Property:                        % To Plaintiff               % To Defendant

UCS-111 (rev:08/11)NEW YORK STATE UNIFIED COURT SYSTEMSUPPORT SUMMARY FORM: FAMILY & SUPREME COURTINSTRUCTION SHEETPrepare one report for each proposed judgment or final order granted pursuant to Article 4 or 5 of the Family Court Act and   DRL §240 and §236 B(9)(b) which includes a provision for child support (including modification of order). SUBMIT COMPLETED FORM TO:Office of Court AdministrationOffice of Court Research25 Beaver Street, Room 975New York, New York 10004GENERAL INSTRUCTIONS:     ÿ    ALL ITEMS MUST BE ANSWERED•If a number or amount in dollars is required and the answer is none, write 0.•If a certain item is not applicable, write NA.•If the information is unknown or not known to the party filling out the form, write UK.•“mm/dd/yy” means “month/day/year”.SPECIAL INSTRUCTIONS FOR PARTICULAR ITEMS:G.Use gross income figures from the last complete calendar year.  Do not include maintenance or child support as income.H.If the child support award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26,if monthly, multiply it by 12.M.If the maintenance award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26;if monthly, multiply it by 12.  If the maintenance award calls for decreasing or increasing amounts (for example, acertain amount for five years and half that amount for another three years), then provide the average of the awards (totalamount for all years divided by the number of years).NOTE:THIS INFORMATION IS CONFIDENTIAL AND WILL BE USED FOR STATISTICAL PURPOSES ONLY.IT WILL NOT BE RETAINED IN THE CASE FILE.