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 › Surrender Forms › Form SURR-4-a - Affidavit of independent witness to execution of extra-judicial surrender of child in foster care (non-agency employee)

Current through Register Vol. 46, No. 28, July
					 10, 2024
Soc. Serv. Law § 383-c(4) Form
						SURR-4-a
(Affidavit of Independent Witness
						to
Execution of Extra-Judicial
						Surrender
of Child in Foster
						Care--Non-agency
Employee)
(9/2006)
FAMILY COURT OF THE STATE OF NEW
						YORK
COUNTY OF
________
In the Matter of the Application for
						Docket No.
Approval of a Surrender Instrument
						Concerning AFFIDAVIT OF INDEPENDENT
WITNESS TO EXECUTION OF
EXTRA-JUDICIAL SURRENDER
CIN # OF CHILD IN FOSTER CARE
Pursuant to Section 383-c of the
						Social
Services Law
________
STATE OF NEW YORK)
) ss.:
COUNTY OF)
I, [specify name of witness]:, having been
						duly sworn, deposes and states the following:
1. [Check all applicable
						box(es)]:[FN1]
I am an attorney at law duly licensed to
						practice under the laws of the State of New York and have an office at [specify
						address]:
I am a certified social worker duly
						licensed to practice under the laws of the State of New York and have an office
						at [specify address]:
I am [specify relationship, if any, to
						person executing surrender and/or child]:
I reside have an office at [specify
						residential or office address]:
2. On [specify date]:, I witnessed the
						execution and acknowledgment of the surrender of the above-named child by
						[specify]: at the following location [specify]:
3. I am not an employee, volunteer,
						consultant or agent of, or attorney for, the authorized agency to which the
						child is being surrendered and I do not serve as the sole non-employee witness
						for the agency. I am not an employee of an agency or organization contractually
						or financially responsible for or involved with the delivery of services to the
						above-named child or his or her family, nor am I related within the second
						degree to any employee-witness to the surrender of the child. Neither I nor my
						employer have received any payment or compensation other than actual and
						reasonable transportation expenses, if any, incurred in order to witness the
						surrender.[FN2]
Form SURR-4-a Page 2
4. The person executing the surrender
						instrument was provided with a copy of the surrender and the surrender was read
						in full in his or her principal language of [specify]:.
The person executing the surrender
						instrument was given an opportunity to ask questions and obtain answers
						regarding the nature and consequences of the surrender, including the
						consequences of, and procedures to be followed in, cases of a substantial
						failure of a material condition, if any, contained in the surrender instrument.
						The person executing the surrender instrument was informed of the obligation to
						provide the authorized agency with a designated mailing address, as well as any
						subsequent changes in such address, at which the person executing the surrender
						may receive notices regarding any substantial failure of a material condition,
						unless this notification is expressly waived by a statement written by the
						person executing the surrender instrument and appended to or included in the
						surrender instrument.
Signature of Independent Witness to
						Execution of Extra-judicial Surrender
Sworn to before me this day of ,
________
Notary Public
(Deputy) Clerk of Court
[FN1] At least one witness must be an
						attorney or certified social worker who is independent of, and not employed by,
						the authorized agency to whom the child was surrendered. See Soc. Ser. Law
						§ 383-c(4)(a).
[FN2] See 18 NYCRR
						§421.6(e).