Complete Form for Each Basic Child Support Obligation Order - New York
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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 decree
by either or both parents or pursuant to a valid agreement between the parties for care, maintenance and education of any unemancipated child
under the age of twenty-one years.
UCS-111 (rev:08/11)
CHILD SUPPORT SUMMARY FORM
SUPREME COURT
COMPLETE FORM FOR EACH BASIC CHILD SUPPORT OBLIGATION ORDER
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A. 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 annually
I. Additional Child Support:
(Circle as many as appropriate)
By Plaintiff: By Defendant:
1. Medical/Med. Ins. 1. Medical/Med. Ins.
2. Child Care 2. Child Care
3. Education 3. Education
4. Other 4. Other
J. Did the court make a finding that the child
support award varied from the Child Support
Standards Act amount? (Circle one)
1. Yes 2. No
K. 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 ONLY
N. Allocation of Property:
% To Plaintiff % To Defendant
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