Fill and Sign the Affidavit in Support of Motion for an Order Approving Form

This application may be made by relatives up to the third degree of consanguinity to either parent, that is, 1adult siblings of the child; grandparents, great-grandparents and great-great-grandparents of the child(ren); aunts,uncles, great-aunts, great-uncles of the child(ren) and their spouses. See 18 N.Y.C.R.R.§443.1(i).F.C.A. §1028-a Form 10-17a(Affidavit in Support of Motion forOrder Approving Relative as FosterParent) (9/2005)FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF......................................................................................In the Matter ofDocket No.A Child Under the Age of 18AFFIDAVIT IN SUPPORT OFAlleged to be GAbused GNeglected byMOTION FOR AN ORDERAPPROVING RELATIVE AS FOSTER PARENT..............................................Respondent(s)........................................STATE OF NEW YORK ) ) SS.:COUNTY OF NEW YORK )I, [specify name]:, swears the following to be true under thepenalties of perjury:1. I am the [specify kinship relationship to the child(ren)]:1and am willing and qualified to provide foster care for the child(ren).2. On [specify date]: , I received a notice that [specify child(ren)]: , the above-named child(ren), was/were removed from his/her/theirhome on [specify date]: and was/were G remanded Gplaced in foster care on [specifydate]: . 3. On [specify date]: , I made a request to [specify official andagency]: to approve me as a foster parent and place the child(ren) inmy care. However, the Department of Social Services has refused my request to place thechild(ren) with me and has given me the following reason(s) for this refusal [specify]: Form 10-17a Page 2 These crimes include: (A) a felony conviction at any time involving: (i) child abuse or neglect; (ii) 2spousal abuse; (iii) a crime against a child, including child pornography; or (iv) a crime involving violence, including rape, sexual assault, or homicide, other than a crime involving physical assault or battery; or(B) a felony conviction within the past five years for physical assault, battery, or a drug-related offense.See Social Services Law §378-a.4. I believe I am qualified to provide foster care for the child(ren) and that it would be inthe best interests of the child(ren) to be placed in my care for the following reason(s)[explainfully]:5. (a). (Upon information and belief), neither I nor anyone over the age of 18 living in myhome have been the subject of an indicated report of child abuse or maltreatment, as such termsare defined in section 412 of the Social Services Law, or has been the respondent in a childprotective proceeding that resulted in an order finding that any child is an abused or neglectedchild, except [specify]: (b)[Check applicable box(es)]: Upon information and belief, G Neither I nor any other adult over the age of 18 residing in my home have a criminalconviction. G I have been convicted of the following offenses [specify, including dates ofconvictions and sentences]:[Applicable if my criminal conviction is for a felony listed in Social Services Law §378-a]:2G Denial of my application to be approved as a foster parent and to provide foster care tothe child(ren) will create an unreasonable risk of harm to their physical or mental health andgranting my application will not place the child(ren)’s safety in jeopardy and will be in the bestinterests of the child(ren) for the following reasons [specify]:G The following adult over the age of 18 living in my home [specify]:has the following criminal conviction(s) [specify, including dates of convictions and sentences]:WHEREFORE, for the reasons stated above, I respectfully request this Court to issue anorder granting my motion for an Order , pursuant to Section 1028-a of the Family Court Act, placing the above-named child(ren) in foster care to reside with me, directing the commissionerof social services to commence an investigation of my home within 24 hours and thereafterexpedite my approval or certification, if deemed qualified, as a foster parent. AffiantSworn to before me this day of , (Deputy) Clerk of the CourtNotary Public