Fill and Sign the Family Court Advisory New York State Unified Court Form

F.C.A.§§ 1054, 1057 Form 10-28 (Child Protective – Order Determining Petition for Extension of Supervision of Respondent and/or Release of Child to Respondent or Non- respondent Parent or Legal Custodian) (6/2016) At a term of the Family Court of the State of New York, held in and for the County of , at New York on PRESENT: Hon. Judge ........................................................................... In the Matter of Docket No. FAMILY FILE #: CIN # ORDER DETERMINING PETITION A Child Under Eighteen Years FOR EXTENSION OF of Age Alleged to be “ SUPERVISION OF RESPONDENT 1 GAbused GNeglected by“ RELEASE OF CHILD TO “ RESPONDENT Respondents “ NON-RESPONDENT PARENT, LEGAL CUSTODIAN OR GUARDIAN .............................................................................. The above-named child having been adjudicated by this Court to be [check applicable box(es)]: “ neglected “ abused “ severely abused “ repeatedly abused within the meaning of Article 10 of the Family Court Act; And an Order of Disposition, dated [specify]: , “ placed Respondent [specify]: under the supervision of [specify agency]: until [specify expiration date]: “ released the child to the following Respondent parent or other person legally responsible [specify]: until [specify expiration date]: 1 This form may be used where an order of supervision of the Respondent had been issued together with a release of the child to the Respondent or to a non-respondent parent, legal custodian or guardian, pursuant to Family Court Act §§1054, 1057. It should NOT be used for an extension of an order of supervision of the Respondent issued together with an order of placement under Family Court Act §1055, since, if the child was placed, the order of supervision extends until the completion of the permanency hearing on the placement and may be continued along with the placement. Form 10-28 Page 2 “ released the child to the following non-respondent parent or legal custodian 2 or guardian [specify]: until [specify expiration date]: [Check applicable box(es), if any]: “ And an order of this Court, dated [specify]: , having been issued extending the supervision Respondent for a period of __ months, terminating on [specify date]: “ And an order of this Court, dated [specify]: , having been issued extending the order of release of the child for a period of __ months, terminating on [specify]: And the petition of [specify]: , for an extension of the period of “ supervision of Respondent “ release of the child, sworn to on [specify date]: , having been filed in this Court on [specify date]: And notice having been duly given to the following person(s), who appeared as follows: [specify]: And the matter having duly come on to be heard, and the Petitioner and above-named persons appearing having been given an opportunity to be heard, The Court, after having made an examination and inquiry into the facts and circumstances of the case and into the surroundings, conditions, and capacities of the persons involved, finds and determines the following: IT IS HEREBY ORDERED that [check applicable box(es)]: A. “ Good cause having been found for the extension of the period of supervision of the Respondent, the petition is GRANTED 3 and the period of supervision is extended for a period of ____ months, pursuant to Section 1057 of the Family Court Act, terminating on [specify date]: , subject to further orders of the Court. OR “ Good cause having not been found for the extension of the period of supervision of the Respondent, the petition for extension of such supervision is DENIED. B. “ Good cause having been found for the extension of the period of release of the child to the “ Respondent “ Non-respondent parent or legal custodian or guardian, the petition is GRANTED 4 and the period of release is extended for a period of ____ months, terminating on 2 “Legal custodian” refers to an individual with an order of custody issued prior to, and separate from, the child protective proceeding. A release to such an individual is distinguished from a child placed in the custody of an individual pursuant to an order of custody issued under Article 6 and section 1055-b of the Family Court Act. Such a custody order results in the termination of all orders under Article 10 of the Family Court Act, would not be deemed a “release” of the child and would thus not be the subject of an extension petition. 3 The total period of supervision, including the original period and any extensions, cannot exceed two years. 4 The total period of release, including the original period and any extensions, cannot exceed two years. Form 10-28 Page 3 [specify date]: , subject to further orders of the Court. OR “ Good cause having not been found for the extension of the period of release of the child to the “ Respondent “ Non-respondent parent or legal custodian or guardian, the petition for extension of such release is DENIED. [Applicable where petition to extend supervision of the Respondent is granted]: “ ORDERED that [specify Respondent(s)]: shall comply with the following terms and conditions of supervision [specify]: “ ORDERED that [specify Respondent(s)]: shall comply with upon the terms and conditions specified in the annexed Family Treatment Court agreement, dated [specify]: “ ORDERED that the child protective agency, social services official or duly authorized agency [specify]: shall provide the following services and/or perform the following supervisory actions [specify]: “ ORDERED that [specify Respondent(s)]: (is)(are) required to comply with the terms and conditions specified in the order of protection, issued pursuant to Family Court Act §1056, annexed to this order and made a part thereof. [Applicable where petition to extend release of the child to non-respondent parent or legal custodian or guardian is granted]: “ ORDERED that, during the period of release, the non-respondent parent or legal custodian or guardian shall submit to the jurisdiction of the Court with respect to the child and shall cooperate with respect to making the child available for court-ordered visitation with respondents, siblings and others, appointments with the child’s attorneys and clinicians and other individuals or programs providing services to the child, visits (including home visits) by the child protective agency “ and the following additional direction(s) [specify]: “ ORDERED that, during the period of release, the following respondent parent(s)[specify]: “ shall “ shall not be under the supervision of a child protective agency, social services official, or duly authorized agency pursuant to section 1057 of the Family Court Act: “ upon the following terms and conditions to be met by Respondent(s) [specify]: “ upon the terms and conditions specified in the annexed Family Treatment Court agreement, dated [specify]: “ upon the performance of the following supervisory actions by the child protective agency, social services official or duly authorized agency [specify]: “ ORDERED that, during the period of release, the individual to whom the child has Form 10-28 Page 4 been released under this Order may [check applicable box(es)]: “ enroll the child in public school in the applicable school district and, upon verifying the Order and that the individual resides within the district, such district shall enroll the child; “ enroll the child in their employer-based health insurance plan with the same rights as a child for whom the individual is the legal guardian or custodian; and “ make decisions and provide any necessary consents regarding the child’s: “ protection “ education “ care and control “ physical custody “ health and medical needs, provided that this Order does not limit any rights of the child to consent to medical care under applicable laws. IT IS FURTHER ORDERED that the Petitioner shall report to the Court, the parties and the attorney for the child [check applicable box(es)]: “ not later than 60 days prior to the termination of the order, unless a petition for extension of the period of supervision of Respondent and/or release of the child has been filed; 5 and “ during the period of supervision and/or release, Petitioner shall submit progress reports to the Court, the parties and the attorney for the child as follows [specify]: AND IT IS FURTHER ORDERED that [specify]: ENTERED Judge of the Family Court Dated: PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. Check applicable box: “ Order mailed on [specify date(s) and to whom mailed]: “ Order received in court on [specify date(s) and to whom given]: 5 Unless the Court determines that facts and circumstances do not warrant a report, a report 60 days prior to the expiration of the order is required where the extension is issued on consent of the parties and the attorney for the child and may be ordered in the Court’s discretion in other cases. See Family Court Act §§1054(d); 1057(c).