Fill and Sign the 383 C 384 384 C Form

This notice paragraph applies to you IF you have: (i) been adjudicated the father by a court in New York 1State; (ii) been adjudicated the father elsewhere by a court order that has been filed with the national putative fatherregistry; (iii) filed a timely notice of intent to claim paternity and have not revoked it; (iv) been identified as thefather in the child’s birth certificate or in a sworn written statement by the child’s mother; (v) been openly living withthe child’s mother as the child’s parent when the court proceeding was begun or the child was placed with theauthorized agency; (vi) been married to the child’s mother within six months after the child’s birth and beforeexecution of the surrender instrument; or (vii) filed an acknowledgment of paternity with the national putative fatherregistry. S.S.L. § 383-c, 384, 384-c Form SURR-1(Surrender– Notice of Proceeding forFAMILY COURT OF THE STATE OF NEW YORK Approval of Judicial or Extra-judicialCOUNTY OFSurrender Instrument)(9/2006)In the Matter of the Application for Approval Docket No. of a Surrender Instrument Pursuant to Sections 383-c or 384 of the Social Services Law Concerning NOTICE OF PROCEEDING FOR APPROVAL OF CIN#9 JUDICIAL 9 EXTRA-JUDICIALChild’s Name: SURRENDER INSTRUMENTDate of Birth:TO: PLEASE TAKE NOTICE that the annexed petition requesting approval of an instrument of surrenderconcerning the above-named child has been presented to the Family Court of the State of New York, County, located at [specify address]:and that a hearing on the petition will be held on [specify date and time]:at which time you will have an opportunity to be heard. PLEASE TAKE FURTHER NOTICE that you have the right to be represented by a lawyer and, if youare a custodial or non-custodial parent, guardian, grandparent, foster parent or other person havingphysical or legal custody of the above-named child and the Court finds that you are unable to pay for alawyer, you have the right to have a lawyer assigned by the Court. FAILURE TO APPEAR MAY RESULT, WITHOUT FURTHER NOTICE, IN COURTAPPROVAL OF THE SURRENDER INSTRUMENT AND TRANSFER OF CUSTODY ANDGUARDIANSHIP OF THE CHILD TO A SOCIAL SERVICES OFFICIAL OR AUTHORIZEDAGENCY FOR THE PURPOSE OF ADOPTION. NOTICE TO ADJUDICATED, ACKNOWLEDGED OR IDENTIFIED FATHERS, pursuant toSocial Services Law §384-c: You have a right to appear to present evidence to the Family Court 1relevant to the best interests of the child. Your failure to appear will be considered a denial of yourinterest in the child and may result, without further notice, in court approval of the surrender instrumentand transfer of custody and guardianship of the child to a social services official or authorized agency forthe purposes of adoption.Dated: ___________________________________ Name of Attorney(s) ___________________________________ Attorney(s) for Petitioner: ___________________________________ Mailing Address ____________________________________ Telephone Number