New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter IV - Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) › Subchapter A - Forms Authorized by Section 205.7 › Foster Care Forms (Social Services Law Section 358-A) › Form 358-a-6 - Petition for pre-placement approval of standby placement instrument

Current through Register Vol. 46, No. 28, July
					 10, 2024
Soc. Serv. Law §§ 358-a,
						384-a(2)(h) Form 358-a-6
(Petition for Pre-placement
Approval of Standby
Placement Instrument)
9/2006
FAMILY COURT OF THE STATE OF NEW
						YORK
COUNTY OF
________
In the Matter of the Application for
						Docket No.
Approval of an Instrument
						Concerning
PETITION FOR
PRE-PLACEMENT APPROVAL OF
STANDBY PLACEMENT
INSTRUMENT
CIN #
Pursuant to Section 358-A of the
						Social
Services Law
________
NOTICE: PLACING YOUR CHILD IN FOSTER CARE
						MAY RESULT IN LOSS OF YOUR RIGHTS TO YOUR CHILD. IF YOUR CHILD STAYS IN FOSTER
						CARE FOR 15 OF THE MOST RECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAW TO
						FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END
						OF THE 15-MONTH PERIOD.
TO THE FAMILY COURT:
The undersigned Petitioner respectfully
						shows that:
1. The Petitioner is authorized to file
						this petition in that (s)he is an official of the Department of Social Services
						for County and has (his)(her) office and place of business at
2(a). The above-named child is a
						(female)(male), born on.
(b) . The names and addresses of the birth
						parents or legal guardians of said child are as follows:
Name Address
(c) . The child (is) (is not) a
						Native-American child subject to the Indian Child Welfare Act of 1978
						(25 U.S.C. §§
												1901 -
						1963).
Form 358-a-6 Page 2
(d) The child resides with [specify] :,
						the [specify relationship] of the child, at [specify address]:
3. (a) Petitioner has determined that the
						child is at significant risk of foster care placement during the next 18 months
						because the (parent)(legal guardian) is suffering from a progressively chronic
						or irreversibly fatal illness and has no relative or close friend available to
						designate as a standby guardian.
(b) A written instrument, pursuant to
						Social Services Law § 384-a, was executed by [specify]:, the
						(parent)(legal guardian) of the child, requesting that the child be transferred
						to the care and custody of [specify authorized agency]: (to reside with
						[specify prospective foster parent; delete if inapplicable] :) at such time as
						the (parent)(legal guardian) dies or becomes debilitated or
						incapacitated.
(c) [Applicable where specific prospective
						foster parent has been identified in instrument; check applicable box]:
The prospective foster parent was found
						qualified and was certified as a foster parent on [specify date]:
The prospective foster parent has not yet
						been found qualified and has not yet been certified as a foster parent. The
						investigation and certification process will be completed by [specify date]:,
						at which time a report on the outcome will be furnished to all parties,
						including the law guardian, and to the Court.
4. [Applicable where transfer made
						pursuant to Section
						384-a of
						the Social Services Law] Pursuant to the attached instrument, (has) (have)
						consented to the jurisdiction of the Family Court over this proceeding and
						(has)(have) waived service of the petition and notice of this
						proceeding.
5. The names and last-known addresses of
						the childs parents and all other persons required to be given notice of this
						proceeding pursuant to Sections
						358-a and
						384-c of
						the Social Services Law are:
Name Address Relationship
and there are no persons other than those
						set forth who are entitled to notice.
6. No previous application has been made
						to any court or judge for the relief requested herein, (except
.)
WHEREFORE, Petitioner requests:
Form 358-a-6 Page 3
A. That process be served on those
						entitled thereto in accordance with Section
						358-a or
						384-c of
						the Social Services Law; and
B. That the Court enter an order granting
						the petition approving the annexed instrument and approving the transfer of
						custody and (guardianship)(care) to the Social Services official of County,
						such transfer to take effect when the (parent)(legal guardian) dies, becomes
						debilitated or incapacitated and a petition pursuant to Section
						358-a of
						the Social Services Law is granted;
C. That the Court grant such other and
						further relief as the Court may deem just and proper.
Dated:
______________
Petitioner
______________
Print or type name and title
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
______________
______________
______________
Attorney's Address, Telephone #
VERIFICATION
STATE OF NEW YORK
COUNTY OF
ss.:
being duly sworn, deposes and says:
That (s)he is
and is acquainted with the facts and
						circumstances of the above-entitled proceeding; that (s)he has read the
						foregoing petition and knows the contents thereof; that the same is true to
						(his(her) own knowledge except as to those matters therein stated to be alleged
						upon information and belief, and that as to those matters (s)he believes it to
						be true.
Sworn to before me this day of
______________
Petitioner
______________
(Deputy) Clerk of the Court
Notary Public