Affidavit of No Convictions Or Threats Against Custodial Parent And/Or Child(Ren) Or No

Affidavit of No Convictions or Threats against Custodial Parent and/or Child(ren) or No Fraudulent Intentional Program Violations

CSMS Case ID No: ______Local District Name: ______

A. I, the undersigned,______, residing at ______, whose Social Security Number is ______-______-_____, whose date of birth is______, being duly sworn, depose and say that I have not been convicted in the past of any of the following in New York State, or any other state:

(1) Criminal non-support conviction or willful violation of any child support court order resulting in jail sentence;

(2) A crime against the custodial parent named in any child support order to which I am subject;

(3) A crime against the child(ren) named in any child support order to which I am subject; and/or

(4) A crime that resulted in the death of my child, whether the child was my biological child, adopted child, or stepchild, and whether or not the child was considered in a child support order to which I am subject.

(5) In addition, there are no orders of protection currently active against me for the custodial parent or child(ren) named in any child support order to which I am subject.

B. In addition, I have not been convicted of fraudulent intentional program violations in regard to temporary assistance and care (commonly referred to as “welfare fraud”).

C. I understand that failure to disclose, in full, information that is pertinent to the statements above could result in denial of my request for modification of my support order and/or arrears compromise. I further understand that if I present the Support Collection Unit (SCU) with false or misleading information, or a misrepresented claim, which is used as the basis for an Agreement to Modify Order of Support and/or Compromise Arrears (Agreement), and the Agreement is then accepted by the court and a modified order of support is issued based on such information, the SCU may bring a motion to vacate and nullify such order. In such instance, the SCU has the right to request permission from the court to re-apply all amounts affected by the compromise to my account, disregard the modified order, and enforce the prior order. I understand that if the modified order is vacated by the court, the SCU will take any action or institute any and all proceedings which might have been taken if the Agreement had not been entered into.

D. I solemnly affirm under the penalty of perjury that the above information is true to the best of my knowledge, information and belief.

______

Signature of Noncustodial Parent Date

Sworn to before me this _____

Day of , 20___

______

Notary Public

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