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Soc. Serv. Law.§§384-bForm TPR-1 F.C.A § 614 (Termination of Parental Rights – Permanent Neglect) (8/2010) FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF........................................................................................... In the Matter of the Commitment of Docket No. Guardianship and Custody pursuant to § 384-b of the Social Services Law of PETITION (PERMANENT CIN # NEGLECT) A Child under the Age of Eighteen Years, Alleged to be Permanently Neglected Child........................................................................................... IF THIS PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT AND WITHOUT NOTICE TO YOU. IF YOU ARE THE PARENT, FOSTER PARENT OR CUSTODIAN OF THE CHILD, YOU HAVE A RIGHT TO HAVE A LAWYER REPRESENT YOU. IF YOU CANNOT AFFORD A LAWYER, YOU MAY ASK THE COURT TO APPOINT A LAWYER TO REPRESENT YOU WITHOUT FEE. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner(s) , (is) (are) G an authorized agency having its office and place of business at [specify, including county]: G foster parent(s) residing at [specify, including county]: G child’s attorney G guardian ad litem filing at the Court’s direction, pursuant to Soc. Serv. Law §384-b(3)(b). 2 a. is a Gmale Gfemale child under the age of eighteen years, born on [specify]: , at [specify]: , who now resides at [specify, including county]: . 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. The full name and last-known address of each parent and custodian of the child are: Name Last-Known Address Form TPR-1 Page 2 4. a. The name and last-known address of any other interested party who should be afforded notice of this proceeding are: Name Relationship to Child Last-Known Address b. The name and last-known address of any other person entitled to notice of an adoption pursuant to Domestic Relations Law § 111-a are: Name Last-Known Address c. There are no persons other than those set forth entitled to notice of this proceeding or of an adoption of the child. 5. a. The child was removed from his or her home on [specify]: and came into the care of an authorized agency on [specify]: , under the following circumstances: [include court, county, docket number and date(s) of prior proceedings]: b. The child has been in the care of an authorized agency for [check applicable box(es)]: G a continuous one- year period immediately prior to the initiation of this proceeding G 15 of the most recent 22 months. 6. [Check applicable box]:G Upon information and belief, the authorized agency has made diligent efforts to encourage and strengthen the parental relationship as follows [specify efforts]: G Upon information and belief, the authorized agency has not made diligent efforts to encourage and strengthen the parental relationship because of: G a judicial finding that reasonable efforts to reunify the child and the Respondent(s) were not required [specify docket number, court, county and date of such finding]: G the parent failed for a period of six months or more to keep the authorized agency informed as to his or her location; [Applicable where Respondent parent(s) are or were incarcerated or in residential substance abuse treatment during the one-year period immediately prior to the initiation of this proceeding ]:G Upon information and belief, there were no delays or barriers experienced by the Respondent in the prison or treatment center that prevented him/her from keeping the agency informed of his/her location, (except [specify, if any]: . 7. Upon information and belief, [delete if inapplicable]: notwithstanding such efforts, the Respondent parent(s) (has) (have) failed for a period of [check applicable box(es): G at least one year G 15 of the most recent 22 months following the date the child came into the care of the authorized agency Form TPR-1 Page 3 [check applicable box(es): G substantially and continuously or repeatedly to maintain contact with; or G plan for the future of the child, although physically and financially able to do so. [Explain]: 8. [Applicable where respondent parent(s) are or were incarcerated or in residential substance abuse treatment during the one-year period immediately prior to the initiation of this proceeding ]: G Upon information and belief, the facility or program in which Respondent is or was housed provided opportunities for contact with the child as follows [specify]: G Upon information and belief, the facility or program in which Respondent is or was housed provided opportunities for Respondent to receive social or rehabilitative services to aid in the development of a meaningful parent-child relationship as follows {specify]: 9. The best interests of the child require the commitment of the guardianship and custody of the child to G an authorized agency G foster parent(s) for the following reasons [specify; if appropriate, include facts regarding a non-respondent parent]: 10. The child ❑ is ❑is not under the jurisdiction of the Family Court. If so, this petition ❑ has ❑ has not been filed in the Court that exercised jurisdiction over the most recent permanency or other proceeding involving this child. [If it has not been so filed, petitioner must file affirmation, Form TPR-12]. 11. No previous application has been made to any court or judge for the relief sought herein (except [specify]: WHEREFORE, the Petitioner requests an order determining that the above-named child is a permanently neglected child, and committing the guardianship and custody of the child to G an authorized agency G foster parent(s), and for such other and further relief as in the interests of the child may be granted. Dated: . G Agency by: G Foster parent: Name Title Print or type name Signature of Attorney, if any Attorney’s Name (Print or Type) Form TPR-1 Page 4 Attorney’s Address and Telephone Number VERIFICATION (Agency) STATE OF NEW YORK ) ss.: COUNTY OF ) being duly sworn, states the following: That (he) (she) is a duly constituted official of the above-named authorized agency, to wit, its ; That (he) (she) has read the foregoing Petition and knows the contents thereof; that the same is true to (his) (her) own knowledge except as to matters therein stated to be alleged on information and belief and that as to those matters (he) (she) believes it to be true. Agency Official Sworn to before me this day of , . (Deputy) Clerk of the Court Notary Public VERIFICATION (Individual) STATE OF NEW YORK ) )SS.: COUNTY OF ) , being duly sworn, says that (s)he is the Petitioner in the above-entitled proceeding and that the foregoing petition is true to (his) (her) own knowledge, except as to matters herein stated to be alleged on information and belief and 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