Fill and Sign the Acknowledgment of Possible Consequences to Parental Rights Form

NHJB-2209-DF (07/01/2013) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Number: IN THE MATTER OF: DOB: IN THE MATTER OF: DOB: IN THE MATTER OF: DOB: IN THE MATTER OF: DOB: ACKNOWLEDGMENT OF POSSIBLE CONSEQUENCES TO PARENTAL RIGHTS IN ABUSE AND NEGLECT CASES FOR USE WHEN: Pursuant to RSA 169-C:15,IV, at a pre liminary hearing the Court shall determine whether each parent summoned understands the possible consequences to pa rental rights should the Court find the child(ren) is(are) abused and/or neglected and shall have each parent sign a statement to that effect. The filing of a petition pursuant to RSA 169-C alleging that your child(ren) is(are) abused and/or neglected is a serious matter. If the Court determines t hat there is evidence that your child(ren) is(are) abused and/or neglected, the Court’s orders will affect you and your child(ren) and may affect your parental rights whether you are named or unnamed in the abuse and/or neglect petition. 1. Right to an Attorney Pursuant to RSA 169-C:10,II(a), a parent named in an abuse and/or neglect petition has a right to have an attorney at every stage of the abuse and/or neglect proceeding. If you are an accused parent or a non- accused parent who is a household member and you think you cannot afford to pay an attorney and would like to apply for a Court-appointed attorney, you should i mmediately notify the Court. Please note that if you are appointed an attorney, you may be asked to pay back some or all of the Court-appointed attorney’s fees. This will be based upon your ability to pay as determined by your completed Financial Affidavit. 2. Requesting Custody of Your Child A parent who has not been charged with abuse and/or neglect shall, pursuant to RSA 169-C:19-e, be afforded upon request a full Court hearing regarding the parent’s ability to obtain custody of his or her child(ren). At the hearing, the parent shall be provided t he opportunity to present evidence pertaining to his or her ability to provide care for the child and shall be given custody unless it is demonstrated, by a preponderance of the evidence, that the parent is otherwise unfit to perform his or her parental duties. 3. Custody and Placement The Court will determine whether your child(ren) will remain at home or with another parent or whether your child(ren) will be removed and placed in a foster home or another appropriate placement. The Court may impose conditions on any placement it makes, such as your family having regular visitation through the Division for Children, Youth and Families (DCYF). A. Legal Supervision The Court may award, pursuant to RSA 169-C:3,XVIII, legal supervision and permit your child(ren) to remain at home or with another parent under the supervision of DCYF subject to further Court order. B. Protective Supervision The Court may award, pursuant to RSA 169-C:3,XXV, protective supervision to DCYF and place your child(ren) with DCYF pending the adjudicatory hearing. This would give DCYF the right to temporarily remove your child(ren) from parental care and custody and determine where and with whom your child(ren) will live, including a foster home. Case Number: ACKNOWLEDGMENT OF POSSIBLE CONSEQUENCES TO PARENTAL RIGHTS IN ABUSE & NEGLECT CASES NHJB-2209-DF (07/01/2013) Page 2 of 3 C. Legal Custody The Court may award, pursuant to RSA 169-C:3,XVII, legal custody to DCYF, which would give DCYF the following rights and responsibilities unl ess otherwise modified by Court order: (1) The right to determine where and with whom your child(ren) shall live; (2) The right to have the physical possession of your child(ren); (3) The right and duty to protect and constructively discipline your child(ren); and (4) The responsibility to provide your child(ren) with food, clothing, shelter, education, emotional security and ordinary medical care, provided that such rights and responsibilities will be exercised subject to the power, rights, duties and responsibilities of the guardian of the child(ren) and subject to residual parental rights and responsibilities if these have not been terminated by judicial decree. 4. Provision of Services and Social Study The Court may order a child(ren), his/her parents, guardian, custodian, or a household member to submit to a mental health evaluation , or to undergo a physical examination or treatment . A written assessment of the evaluation, examination or treatment will be provided to the Court. If the Court determines that your child(ren) is(are) abused and/or neglected, the Court will order DCYF to submit to the Court a social study consisting of, but not limited to, the home conditions, family background, financial assessment, school record, mental and physical and social history of your family. DCYF will also submit a case plan, which the Court may adopt in whole, in part or not at all in making its orders. The school district may be joined in the matter to determine whether educational services are required for your child(ren). 5. Additional Court Orders The Court may make additional orders designed to protect the health, safety and well-being of your child(ren). 6. A Parent’s Financial Responsibility Parents and other individuals chargeable by law fo r their child's support and necessities may be liable for expenses incurred in this abuse and neglect proceeding, including the costs of certain evaluations and placements. You will be required by the Court to complete a Financial Affidavit. Failure to complete this Affidavit may result in a charge against you of contempt. 7. Confidentiality All Court hearings and records of abuse and neglect cases are confidential. The hearings are not open to the public and only people involved in the case, or invited by the parties and approved by the Court, will be admitted to the Court hearings. 8. A Finding of Abuse or Neglect and a Parent’s Failure to Follow the Court's Orders and Correct the Conditions may be the basis for a Petition To Terminate the Parent’s Parental Rights In New Hampshire, there are several ways that a parent's rights can be terminated; one of them is a finding of abuse or neglect and a parent's failure after twelve (12) months to correct the conditions that led to the finding, whether the parent is named or unnamed in the abuse and/or neglect petition. In the event a petition is filed to terminate your rights as a parent, pursuant to RSA 170-C, you will be notified of the Court hearings. You will have the right to an attorney. If you cannot afford one, the Court will appoint one for you. A guardian ad litem (GAL) will be appointed for your child(ren). At a hearing, both sides will present evidence to the Court concerning the reasons why your rights should or should not be terminated. The Court will make a decision based on the evidence it hears as well as any reports or examinations offered to the Court. If your parental rights are terminated, you will no longer have any legal rights, privileges, duties or obligations regarding your child(ren). Case Number: ACKNOWLEDGMENT OF POSSIBLE CONSEQUENCES TO PARENTAL RIGHTS IN ABUSE & NEGLECT CASES NHJB-2209-DF (07/01/2013) Page 3 of 3 By signing below, you acknowledge that you understand the possible consequences to your parental rights should the Court make a finding of "TRUE" that your child(ren) is(are) abused and/or neglected. Date Signature of Parent Printed Name of Parent Signature of Parent’s Attorney (if applicable) Printed Name of Parent’s Attorney (if applicable) I have reviewed the content of this form with the above-named parent and have determined that s/he understands the possible consequences to her/his parental rights should the Court make a finding of "TRUE" that the child(ren) is(are) abused and/or neglected. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and ag ree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge