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 › Child Protective Forms (Family Court Act Article 10) › Form 10-17a - Affidavit in support of motion for order approving relative as foster parent

Current through Register Vol. 46, No. 28, July
					 10, 2024
F.C.A. § 1028-a Form 10-17a
(Affidavit in Support of Motion for
						Order
Approving Relative as Foster
						Parent)
(9/2006)
FAMILY COURT OF THE STATE OF NEW
						YORK
COUNTY OF
________
In the Matter of
Docket No.
CIN# AFFIDAVIT IN SUPPORT OF
A Child Under the Age of 18 MOTION FOR AN
						ORDER
Alleged to be Abused Neglected by
						APPROVING RELATIVE
AS FOSTER PARENT
________Respondent(s)________
STATE OF NEW YORK)
) SS.:
COUNTY OF NEW YORK)
I, [specify name]:, swear the following to
						be true under the penalties of perjury:
1. I am the [specify kinship relationship
						to the child(ren)]:[FN1]
and am willing and qualified to provide
						foster care for the child(ren).
2. On [specify date]:, I received a notice
						that [specify child(ren)]:, the above-named child(ren), was/were removed from
						his/her/their home on [specify date]: and was/were remanded placed in foster
						care on [specify date]:.
3. On [specify date]:, I made a request to
						[specify official and agency]: to approve me as a foster parent and place the
						child(ren) in my care. However, the Department of Social Services has refused
						my request to place the child(ren) with me and has given me the following
						reason(s) for this refusal [specify]:
4. I have never refused on any prior
						occasion to provide care for the child(ren).
On [specify date]:, I was asked by
						[specify]:
to provide care for the child(ren), but I
						was unable to do so at that time because of a lack of [check box(es)]:
						sufficient financial resources appropriate housing appropriate educational
						arrangements other reason [specify]:
Form 10-17a Page 2
5. I believe I am qualified to provide
						foster care for the child(ren) and that it would be in the best interests of
						the child(ren) to be placed in my care for the following reason(s)[explain
						fully]:
6. (a). (Upon information and belief),
						neither I nor anyone over the age of 18 living in my home have been the subject
						of an indicated report of child abuse or maltreatment, as such terms are
						defined in section
						412 of the
						Social Services Law, or has been the respondent in a child protective
						proceeding that resulted in an order finding that any child is an abused or
						neglected child, except [specify]:
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
Neither I nor any other adult over the age
						of 18 residing in my home have a criminal conviction.
I have been convicted of the following
						offenses [specify, including dates of convictions and sentences]:
[Applicable if my criminal conviction is
						for a felony listed in Social Services Law § 378-a]:[FN2]
Denial of my application to be approved as
						a foster parent and to provide foster care to the child(ren) will create an
						unreasonable risk of harm to their physical or mental health and granting my
						application will not place the child(ren)'s safety in jeopardy and will be in
						the best interests of the child(ren) for the following reasons
						[specify]:
The following adult over the age of 18
						living in my home [specify]:
has the following criminal conviction(s)
						[specify, including dates of convictions and sentences]:
WHEREFORE, for the reasons stated above, I
						respectfully request this Court to issue an order granting my motion for an
						Order, pursuant to Section
						1028-a of
						the Family Court Act, placing the above-named child(ren) in foster care to
						reside with me, directing the commissioner of social services to commence an
						investigation of my home within 24 hours and thereafter expedite my approval or
						certification, if deemed qualified, as a foster parent.
Affiant
Sworn to before me this day of ,
________
(Deputy) Clerk of the Court
Notary Public
[FN1] This application may be made by
						relatives up to the third degree of consanguinity to either parent, that is,
						adult siblings of the child; grandparents, great-grandparents and
						great-great-grandparents of the child(ren); aunts, uncles, great-aunts,
						great-uncles of the child(ren) and their spouses. See 18 N.Y.C.R.R.
						§443.1(i).
[FN2] These crimes include: (A) a felony
						conviction at any time involving: (i) child abuse or neglect; (ii) spousal
						abuse; (iii) a crime against a child, including child pornography; or (iv) a
						crime involving violence, including rape, sexual assault, or homicide, other
						than a crime involving physical assault or battery; or (B) a felony conviction
						within the past five years for physical assault, battery, or a drug-related
						offense. See Social Services Law § 378-a.