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-3 - Petition for approval of extra-judicial surrender instrument

Current through Register Vol. 46, No. 28, July
					 10, 2024
Soc. Serv. Law §§ 383-c, 384
						Form SURR-3
(Petition for Approval of Extra-
Judicial Surrender Instrument)
(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 PETITION FOR APPROVAL
OF EXTRA-JUDICIAL
Child's Name: SURRENDER INSTRUMENT
Date of Birth:
CIN#
Pursuant to Section 383-c 384 of the
						Social
Services Law
________
TO THE FAMILY COURT OF THE COUNTY OF
						:
The undersigned Petitioner respectfully
						alleges upon information and belief that:
1. Petitioner, [specify]:, is an
						authorized agency having its office and place of business at [specify]: in the
						County of [specify]:, State of New York.
2. a. The child, [specify]:, is a [check
						applicable box]:
male female child under the age of
						eighteen years, born on [specify date]:
at [specify]:, who now resides in the
						County of [specify]:, State of New York.
b. The subject child is is not a
						Native-American child, who is subject to the Indian Child Welfare Act of 1978
						(25 U.S.C. §§
												1901 -
						1963). If so, the
						following have been notified [check applicable box(es)]: parent/custodian
						[specify name and give notification date]:
tribe/nation [specify name and give
						notification date]:
United States Secretary of the Interior
						[give notification date]:
3. a. The child is now in the custody of
						the Petitioner and resides with [specify, unless confidential]:
b. [Applicable to surrenders pursuant to
						Social Services Law § 383-c]: The child entered foster care on [specify]:
						as a result of [specify proceeding, docket number court and status]:
The most recent permanency hearing was
						held in [check applicable box]: this Court another Court [specify]: on [specify
						date]:
4. The guardianship of the person and
						custody of the child have been committed to the Petitioner by a written
						instrument of surrender, signed on [specify date]: by [check applicable
						box(es)]:
a. mother [specify]:
Form SURR-3 Page 2
b. father [specify]:
[Applicable if surrender executed by
						father]:
Paternity was established by [check
						applicable box; if not established, so state]:
Marriage between the above-named
						parents.
An order of filiation entered on [specify
						date and court]:
An acknowledgment of paternity signed on
						[specify date]:
c. legal guardian [specify]:
5. [Applicable if surrender was executed
						by one parent or by legal guardian]: The child's parent or parent(s), other
						than the parent(s) who executed the surrender, is or are as follows [check
						applicable box(es)]:
a. The child's mother [specify]:
retains parental rights to the
						child.
is or was the subject of the following
						child abuse, child neglect, foster care placement or review and/or child
						custody proceeding(s) [specify type of proceeding, court, docket number, date
						filed, final disposition or order,
if any, and current status of proceeding,
						if available]:
surrendered the child on [specify
						date]:
is the subject of a pending surrender
						proceeding [specify date filed, court and status]:
had her rights to the child terminated on
						[specify date]:
is the subject of a pending termination of
						parental rights proceeding [specify date filed, court and status]:
is deceased is unknown.
b. The child's father is [specify]:
1). Paternity was established by [check
						applicable box; if not established, so state]:
Marriage between the above-named
						parents.
An order of filiation entered on [specify
						date and court]:
An acknowledgment of paternity signed on
						[specify date]:
2). The child's father [specify]:
retains parental rights to the
						child.
is or was the subject of the following
						child abuse, child neglect, foster care placement or review and/or child
						custody proceeding(s) [specify type of proceeding, court, docket number, date
						filed, final disposition or order,
if any, and current status of proceeding,
						if available]:
surrendered the child on [specify
						date]:
is the subject of a pending surrender
						proceeding [specify date filed, court and status]:
had his rights to the child terminated on
						[specify date]:
is the subject of a pending termination of
						parental rights proceeding [specify date filed, court and status]:
Form SURR-3 Page 3
is deceased.
is unknown.
6. In addition to the above-named child's
						parent(s) or guardian(s), the following individuals must be notified of this
						proceeding, pursuant to Social Services Law § 384-c [specify]:
Name Address [unless confidential]
						Relationship
There are no persons other than those set
						forth above entitled to notice pursuant to Section
						384-c of
						the Social Services Law.
7. a. [Applicable to surrender of child in
						foster care]: The instrument of surrender was executed and acknowledged before
						[specify at least two witness(es)]:, whose affidavit(s) (is)(are) attached to,
						and made a part of, this petition.[FN1]
b. [Applicable to surrender of child not
						in foster care]: The instrument of surrender was executed and acknowledged
						before [specify at least one witness]:
8. [Applicable to surrender of child in
						foster care; check applicable box(es)]:
a. Supportive counseling for the person
						executing the surrender was offered arranged by [specify]:, an employee of the
						following authorized agency [specify]:
, whose affidavit is attached to, and made
						a part of, this petition.[FN2]
b. Supportive counseling for the person
						executing the surrender was:
provided by [specify]:, whose affidavit is
						attached to, and made part of, this petition. The counseling was provided on
						[specify date]:
as follows [specify]:
not provided because:
the offer of counseling was rejected by
						the person executing the surrender other reason [specify]:
9. a. The surrender is subject to the
						following condition(s) [specify]:
b. [Applicable where surrender is subject
						to condition of adoption by specific individual]: The surrender is conditional
						upon adoption by [specify]:, who, in accordance with regulations of the NYS
						Office of Children and Family Services, has been [check applicable
						box(es)]:
investigated and approved as a prospective
						adoptive parent certified or approved as a foster parent
c. [Applicable where post-adoption
						contact agreement has been signed]: The annexed post- adoption contact
						agreement is in the child's best interests for the following reasons [specify]:
						The agreement has been consented to in writing by the following
						[specify]:
Form SURR-3 Page 4
Adoptive parent(s) [specify]:
Birth parent(s) [specify]:
Adoptive child's Law guardian
						[specify]:
Sibling(s) or half-sibling(s) over the age
						of 14, if contact is with siblings or half-siblings [specify]:
10. The parent or guardian who executed
						the surrender [check applicable box]: [FN3] signed did not sign a written
						statement included in or appended to the surrender instrument waiving written
						notice of any substantial failure of a material condition.
11. No previous application has been made
						for the approval of this instrument of surrender to any court of judge, except
						[specify; delete if inapplicable]:
WHEREFORE, Petitioner requests that this
						Court enter an order approving the surrender instrument on such notice to such
						persons as the Court may in its discretion provide [delete if inapplicable]:
						and approving the attached post-adoption contact agreement, and granting such
						other and further relief as this Court deems just and proper.
______________
Petitioner
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
______________
Attorney's Address and Telephone #
VERIFICATION
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,.
________
(Deputy) Clerk of the Court
(Notary Public)
[FN1] One witness must be an employee of
						the authorized agency trained to receive surrenders and one witness must be an
						attorney or certified social worker not employed by and independent of the
						authorized agency. See Social Services Law § 383-c(4).
[FN2] If the employee responsible for
						arranging for supportive counseling is the same employee who witnessed the
						surrender, a combined affidavit (Form SURR-4) may be submitted.
[FN3] Include a separate paragraph for
						each person who executed the surrender.