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 Sections 384, 384-C) › Form 384-1 - Petition for approval of surrender instrument

Current through Register Vol. 46, No. 28, July
					 10, 2024
Soc. Serv. Law §§ 384, 384-c
						Form 384-1
(Petition for Approval of
Surrender Instrument)
12/97
FAMILY COURT OF THE STATE OF NEW
						YORK
COUNTY OF
________
In the Matter of the Application
						for
Approval of a Surrender Instrument
						(Docket)(File) No.
Concerning
PETITION FOR
APPROVAL OF
SURRENDER
INSTRUMENT
(CHILD NOT IN
Pursuant to Section 384 of the Social
						FOSTER CARE
Services Law CARE)
________
TO THE COURT OF THE COUNTY OF :
The undersigned Petitioner respectfully
						alleges that:
1. Petitioner is an authorized agency
						having its office and place of business at in the County of, State of New
						York.
2(a)., is a (fe)male child under the age
						of eighteen years, born on at who now resides in the County of, State of New
						York.
2(b). The subject child (is) (is not) a
						Native American child subject to the Indian Child Welfare Act of 1978
						(25 U.S.C. §§
												1901 -
						1963).
3. The child is now in the custody of the
						petitioner and resides at
4. The guardianship of the person and
						custody of the child have been committed to the petitioner by a written
						instrument of surrender, signed by
[Delete inapplicable provisions]:
(c) . The child (is) (is not) a
						Native-American child subject to the Indian Child Welfare Act of 1978 (
(b) (, (mother) (father) of the child,
						(father) (mother) being deceased.
Form 384-1 page 2
(c) (, (mother) (father) of the child,
						(father) (mother) having abandoned the child for a period of six months
						immediately preceding the filing of this petition).
(d) (, mother of such child, who was born
						out of wedlock and by, father of such child whose consent is required pursuant
						to Section
						111 of
						the Domestic Relations Law)
(e) (, guardian of the person of such
						child lawfully appointed by (the Court of County, State of)() (both parents of
						such child being dead) (said child being born out of wedlock and the mother of
						such child being deceased) with the approval of the ( Court)
() herewith attached and made a part
						hereof) in accordance with Section
						384 of the
						Social Services Law; a copy of the instrument of surrender being attached
						hereto and made a part hereof.
5. The names and last known addresses of
						the child's parents and all persons required to be given notice of this
						proceeding are:
Name Address Relationship
and there are no persons other than those
						set forth above who are entitled to notice pursuant to Section
						384-c of
						the Social Services Law.
6. No previous application has been made
						for the approval of this instrument of surrender to any court or judge
						(except
).
WHEREFORE, Petitioner prays that this
						Court enter an order approving such instrument on such notice to such persons
						as the Court may in its discretion provide.
______________
Petitioner
______________
Title
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone
						Number
Form 384-1 Page 3
VERIFICATION IN PROCEEDING
BY GOVERNMENTAL AGENCY
STATE OF NEW YORK)
) ss.:
COUNTY OF)
, 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.
______________
Petitioner
Sworn to before me this day of, 19.
______________
(Deputy) Clerk of the Court
Notary Public