Fill and Sign the Family Court of the State of New York County of Westchester Form

F.C.A. §1022Form10-1c(Child Protective-Application forPre-petition Temporary Removal ofChild(ren) From Home)8/2010FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF In the Matter ofDocket No.CIN #A Child(ren) Under the Age of EighteenAlleged to be APPLICATION FOR“Abused “Neglected by PRE-PETITION TEMPORARY REMOVALOF CHILD(REN) FROMHOMERespondent(s) NOTICE:IF YOUR CHILD STAYS IN FOSTER CARE FOR 15 OF THE MOSTRECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAWTO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTSAND MAY FILE BEFORE THE END OF THE 15-MONTH PERIOD. IFSEVERE OR REPEATED ABUSE IS PROVEN BY CLEAR ANDCONVINCING EVIDENCE, THIS FINDING MAY CONSTITUTE THEBASIS TO TERMINATE YOUR PARENTAL RIGHTS. IF THEPETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOURCHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOURCONSENT. TO THE FAMILY COURT:The undersigned, , is [check applicable box]:G the [state title, agency and county]: a duly authorized child protective agency, with offices at [specify]: “ a person authorized by the Court [specify]:and respectfully alleges that:1.a. (Upon information and belief,) the child(ren) who are the subject(s) of thisapplication is/are: The child(ren) who (is) (are) the subject(s) of this proceeding (is)(are):Name Sex Date of Birth Custodial Parent/Guardian Child’s Address b. (Upon information and belief) The father and mother of the child(ren) and their Form 10-1c Page 2respective residence addresses are:Name of Child(ren) Name of Parent Parent’s Address 2.. (Upon information and belief,), the child(ren) require immediate protection and shouldbe temporarily removed from home prior to the filing of a child protective petition for thefollowing reasons: a. The parent or other person legally responsible for the child(ren)’s care was:G absent; G present but refused, when asked, to consent to the child(ren)’s temporary removaland was informed of this application; b. The child(ren) appear(s) to suffer from abuse or neglect such that immediateremoval is necessary to avoid imminent danger to the child’s life or health, because [specify]: c. There is not enough time to file a petition and hold a preliminary hearing pursuantto Family Court Act §1027. 3. The subject child “ is “ is not a Native-American child, who is subject to the IndianChild 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]: 4. a. Continued placement in the parent’s home [check applicable box]:Q would Q would not be contrary to the child(ren)’s best interests, based upon the followingfacts and for the following specific reasons [specify]: This assertion is based upon the following specific documents and evidence: “ Report of suspected abuse or maltreatment, dated [specify]:“ Case record, dated [specify]:“ Service Plan, dated [specify]:“ The report of [specify]: , dated [specify]:“ Other [specify]: ; AND b. Reasonable efforts, where appropriate, to prevent or eliminate the need for removalof the child(ren) from the home: “ were made as follows [specify reasonable efforts, including specific documents or evidence supporting findings]: “ were not made but the lack of efforts was appropriate [check all applicable boxes]:      “  because of a prior judicial finding that the authorized agency was not required to make reasonable efforts to reunify the child(ren) and their parent(s)[specify date of finding]: “ because [specify other reasons]:  Form 10-1c Page 3 “ were not made. This assertion is based upon the following specific documents and evidence: “ Report of suspected abuse or maltreatment, dated [specify]:“ Case record, dated [specify]:“ Service Plan, dated [specify]:“ The report of [specify]: , dated [specify]:“ Other [specify]: 5. No previous application has been made to any court or judge for the reliefrequested herein (except [specify]: ). WHEREFORE, the undersigned requests that an order be made pursuant to FamilyCourt Act §1022 temporarily removing the child(ren) from the home of [specify parent(s) orperson(s) legally responsible]:and placing the child(ren) temporarily in the care and custody of the Department of SocialServices of [specify county]:County, pending the filing of a child protective petition andthe convening of a hearing pursuant to Family Court Act §1027, and directing such other andfurther relief as to the Court may seem just and proper.Dated: (Agency)By: (Title)VERIFICATIONSTATE OF NEW YORK ) ) ss.:COUNTY OF ) , being duly sworn,deposes and says:That (s) he is the [specify title and agency]: G an authorized child protective agency G person authorized by the Family Court , and is acquainted with the facts and circumstances therein;that (s) he has read the foregoing and knows the contents thereof; that the same is true to (his)(her) ownknowledge, except as to matters therein stated to be alleged on information and belief and as to thosematters (s) he believes it to be true. Name Sworn to before me thisTitle day of , . (Deputy)(Clerk of Court) (Notary Public)