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 - Affidavit of authorized agency employee witness to execution of extra-judicial surrender of child in foster care

Current through Register Vol. 46, No. 28, July
					 10, 2024
Soc. Serv. Law § 383-c(4) Form
						SURR-4
(Affidavit of Authorized Agency
Employee Witness to Execution of
Extra-Judicial Surrender of Child
						in
Foster Care)
(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 AUTHORIZED
AGENCY EMPLOYEE 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. I am an employee of the following
						authorized agency [specify]: and have been trained to receive surrenders in
						accordance with regulations of the New York State Office of Children and Family
						Services.
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. 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.
4. [Applicable where employee-witness was
						also the employee responsible for arranging supportive counseling]:
Form SURR-4 Page 2
a. I am responsible for arranging
						supportive counseling for parents or guardians who execute extra- judicial
						surrenders of children in foster care.
b. On [specify date]:, I arranged for
						supportive counseling for [specify person executing surrender]: to be provided
						by [specify]: as follows [specify]:
c. On [specify date]:, [specify person
						executing surrender]:
accepted did not accept the offer of
						supportive counseling.
d. [Check applicable box or delete
						inapplicable provision]: Upon information and belief,
Supportive counseling was provided to the
						person executing the surrender as follows [specify date, provider and nature of
						supportive counseling]:
Supportive counseling was not provided to
						the person executing the surrender.
____________________
Signature of Witness to Execution of
						Extra-judicial Surrender
Sworn to before me this day of ,
________
Notary Public
(Deputy) Clerk of Court