Identifying Information - New York State Office of ...



OCFS- 6036 (Revised 6/2017) NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESChild Support Obligation StatementChild Day Care ProgramsProgram Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Facility ID Number: FORMTEXT ????? FORMTEXT ?????Instructions: This form must be completed for all child day care programs except for corporations and limited liability companies. If you are four or more months behind in your child support obligations, General Obligations Law requires that OCFS issue you a license for no longer than a period of six months.StatementsAs of the date of this application, do you have an obligation to pay child support? FORMCHECKBOX No, I do not. FORMCHECKBOX Yes, I am under an obligation to pay child support. If you answered “Yes,” please check any of the following conditions that apply to you. FORMCHECKBOX I am not four months or more in arrears in the payment of child support. FORMCHECKBOX I am making payments by income execution, by court agreed payment or repayment plan, or by a plan agreed to by the parties to the support proceeding. FORMCHECKBOX My child support obligation is the subject of a pending court proceeding. FORMCHECKBOX I am currently in receipt of public assistance or supplemental security income (SSI). FORMCHECKBOX None of the above apply.left3556000Notarized Signed CertificationALL APPLICANTS MUST SIGN THIS FORM IN THE PRESENCE OF A NOTARY PUBLICI hereby attest that the information provided by me in this certification is true and accurate to the best of my knowledge. I acknowledge that this statement is given under oath.Applicant Signature: 136207512065Sign in the presence of a notary00Sign in the presence of a notaryApplicant Printed Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sworn to before me this 16097255715Day00Day2867025142240Year00Yearday of 6572255714Month00MonthNotary Public – State of New York (affix stamp) ................
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