Fill and Sign the Fca661 Form 6 1 a Scpa 1701 1704 Petition by

A “permanent guardian” may be appointed, pursuant to Family Court Act §661(b) and Surrogate’s Court 1Procedure Act §1702(2), if the Court finds that it is in the best interests of a person under the age of 21, who has beencommitted to an authorized agency through termination of parental rights or surrender or whose birth parents or otherpersons entitled to notice of, or to consent to, adoption are deceased. Persons over the age of 18 must consent to such anappointment, which may last until the person reaches the age of 21. Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an 2unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an 3unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). F.C.A. § 661;Form 6-1S.C.P.A.§§ 1701 - 1704(Petition for Appointment As Guardian of a Person Or Permanent Guardian) 3/2009.................................................................. Proceeding for the Appointment of aGuardian of the Person or Permanent Guardian ofDocket No.Family File No.PETITION FOR APPOINTMENT AS”Guardian of Person A Person Under the Age of 21”Permanent Guardian................................................................. TO THE FAMILY COURT:The Petitioner respectfully alleges to this Court that: 1. I am [specify relationship]: of the person under the age of21 who is the subject of this petition and I am submitting this petition in order to be appointed[check applicable box]: ”Guardian of the Person ”Permanent Guardian.12. My name is [specify]: and I live at [specifyname and complete address of residence]:23. The name, date of birth and residence of the person under the age of 21 who is thesubject of this proceeding are as follows:Name:Date of Birth:Complete address:3 Form 6-1 Page 2 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an 4unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). Include Mental Hygiene Legal Services, if the subject of the proceeding is mentally retarded or 5developmentally disabled and has been admitted to a facility, and any person entitled to notice of or consent to theadoption of the subject of the proceeding.4. The subject of this proceeding Gis Gis not a Native American child under theage of 18 who is subject to the Indian Child 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]:5. The name and relationship of person with whom the subject of this proceedingresides are as follows:Person with whom subject resides [specify name]:Relationship to subject:Address [include street, city, village or town, county and state]:46. (Upon information and belief) The religion of the person who is the subject of thisproceeding is7. The names, relationship and post office addresses of the birth parents of the subjectof the proceeding, the name and address of the person with whom the subject resides, if otherthan the parent(s), on whom process should issue; and such other persons concerning whom thecourt is required to have information, are as follows: [If either birth parent is dead or hassurrendered or has had parental rights terminated (TPR) , so allege; if both parents are dead,indicate nearest adult next of kin]:Relationship Name Complete Address Deceased? TPR? Surrender? Birth mother:Birth father:Person with whom the subject resides, if other than parents:Adult next of kin, if birth parents are dead:Other [specify]: 5 Form 6-1 Page 38. a. Appointing me as the ”guardian of the person ”permanent guardian would be in [subject’s name]: best interests and would preserve his/her legalrights because [specify facts regarding the suitability, ability and commitment of the proposed guardian to assume full legal responsibility and raise him/her to adulthood]: b. [Required where appointment of permanent guardian is requested, pursuant toFamily Court Act §661(b) or S.C.P.A. §1702(2); delete if inapplicable]: (i) [Check applicable box]:“ guardianship and custody have been committed to the following authorizedagency [specify, include whether by surrender or termination of parental rightsand attach certified copies of the orders terminating parental rights or approvingthe surrenders, as applicable]: “ both parents of the child, whose consent to or notice of an adoption wouldhave been required, are deceased [attach death certificates].(ii) The local social services district performed an assessment, as required byS.C.P.A. §1704(8), that recommended the following [specify and attach a copy of theassessment]: 9: [Applicable to cases in which child protective petition or permanency hearing report hasbeen filed regarding the children and in which petitioner is a relative or other non-parent; delete ifinapplicable]: a. G A child protective petition, Docket # [specify]: , was filed in FamilyCourt, [specify county]: on [specify date]: alleging that [specify names ofrespondents on that petition]:neglected or abused the above-named child(ren). The petition resulted in [specify whether finding wasmade and, if so, the disposition; if the disposition has been adjourned pending a consolidated hearing withthis petition, pursuant to F.C.A. §1055-b, so indicate and give next court date]: b. G A permanency report, Docket # [specify]: , pursuant to Article 10-A ofthe Family Court Act, was filed in Family Court, [specify county]: on [specify date]: indicating a permanency plan of guardianship of the child(ren) with Petitioner in this proceeding. Thepermanency hearing was adjourned to [specify date]: pending a consolidated hearing withthis petition, pursuant to F.C.A. §1089-a. c. The child’s birth mother Q has Q has not consented to the award of guardianship to thePetitioner. If not, the following extraordinary circumstances support Petitioner’s standing to seek Form 6-1 Page 4guardianship of the child(ren) [specify]: d. The child’s legally-established birth father Q has Q has not consented to the award ofguardianship to the Petitioner. If not, the following extraordinary circumstances support Petitioner’sstanding to seek guardianship of the child(ren) [specify]: e. The child has been living with the following foster parent(s)[specify]:since [specify date]:The foster parent(s) G has/have G has/have not consented to the award of guardianship to the Petitioner. [If unawarewhether they have consented, so state]: f. The local department of social services [specify]: in therelated Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award of guardianship to the Petitioner. [If unaware whether they have consented, so state]: g. The attorney for the child(ren) [specify]: in the related Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award ofguardianship to the Petitioner. [If unaware whether they have consented, so state]:9. (Upon information and belief) No guardian pursuant to will or deed, or guardian ofthe person pursuant to Section 384 or 384-b of the Social Services Law, has been previouslyappointed for the subject of this proceeding, except [specify]:10. Upon information and belief, [Check all applicable box(es)]: a. Q I have never been the subject of an indicated report, as such term is defined in ofthe Social Services Law §412, that has been filed with the statewide register of child abuse andmaltreatment pursuant Social Services Law §422. Q I was the subject of an indicated report, as defined in of the Social Services Law§412, that was filed with the statewide register of child abuse and maltreatment pursuant SocialServices Law §422. [Specify the date of the report, determination of whether “indicated” or“unfounded,” status and circumstances to the extent known]: Q I am the subject of a report, as defined in of the Social Services Law §412, filedwith the statewide register of child abuse and maltreatment pursuant Social Services Law §422,that remains under investigation. [Specify the date of the report, status and circumstances to theextent known]: Form 6-1 Page 5 b. Q I have never been the subject of, or the respondent in, a child protectiveproceeding pursuant to Article Ten of the Family Court Act. Q I have been the subject of, or the respondent in, a child protective proceedingpursuant to Article Ten of the Family Court Act. [Specify whether the proceeding resulted in anorder finding that a child or children was/were abused or neglected, indicate whether the subjectof this proceeding was found to be abused or neglected and provide the date and status of theproceeding to the extent known]: c. Q I have never been the subject of an Order of Protection or Temporary Order ofProtection in any criminal, matrimonial or Family Court proceeding(s). Q I have been the subject of an Order of Protection or Temporary Order of Protectionin a criminal, matrimonial or Family Court proceeding(s) as follows [specify the court, docket orindex number, whether I was protected or restrained by the order, date of order, expiration date oforder, next court date and status of case to the extent known]:11. Upon information and belief,[check applicable box(es)]: a. The following adults who are age 18 or older live in my home:Name Relationship, if any, to subject of proceedingDate of Birth b. Q None of the adults 18 or older living in my home has ever been the subject ofany indicated reports, as defined in of the Social Services Law §412, that were filed with thestatewide register of child abuse and maltreatment pursuant Social Services Law §422. Q The following adults 18 or older living in my home have been the subjects ofindicated reports, as defined in of the Social Services Law §412, that were filed with thestatewide register of child abuse and maltreatment pursuant Social Services Law §422. [Specifythe name(s) of the adults, date(s) of the report(s), whether the subject of this proceeding was thesubject of the report(s), status and circumstances to the extent known]: Q The following adults 18 or older living in my home are the subjects of reports,as defined in of the Social Services Law §412, filed with the statewide register of child abuse andmaltreatment pursuant Social Services Law §422, that remain under investigation [Specify thename(s) of the adults, whether the subject of this proceeding is the subject of the report(s),date(s) of the report(s), status and circumstances to the extent known]: Form 6-1 Page 6 c. Q None of the adults 18 or older living in my home has ever been the subjects of, or therespondents in, child protective proceedings pursuant to Article Ten of the Family Court Act. Q the following adults 18 or older living in my home have been the subjects of, or therespondents in, child protective proceedings pursuant to Article Ten of the Family Court Act, asfollows [Specify the names of the adults, whether the proceedings have resulted in orders findingthat the child is an abused or neglected child, whether the subject of this proceeding was a subjectof those proceedings and the date and status of the proceedings to the extent known]: d. Q None of the adults 18 or older living in my home has ever been the subjects of anOrder of Protection or Temporary Order of Protection in any criminal, matrimonial or FamilyCourt proceeding(s). Q the following adults 18 or older living in my home have been the subjects ofOrders of Protection or Temporary Orders of Protection in criminal, matrimonial or Family Courtproceeding(s), as follows [specify the names of the adults, whether the adults are or wererestrained or protected by the order(s), court, docket or index number, date of order, expirationdate of order, next court date and status of cases to the extent known]:12. The birth parent(s) of the child [specify]:although living, should not be appointed guardian of the person of the child because:13. a. [Applicable where the subject of the proceeding is 18 years of age or older;delete if inapplicable]: The person who is the subject of this proceeding is over the age of 18 andhas consented to the appointment of the guardian, a copy of which is attached. b. [Applicable where the child is over 14 years of age but less than 18; delete ifinapplicable]: The child, who is over the age of 14, has expressed a preference for theappointment of the guardian, a copy of which is attached.14. There are no persons interested in this proceeding other than those mentionedabove.15. No prior application has been made to any court, including a Native- Americantribunal, for the relief requested herein (except [specify]: ). WHEREFORE, Petitioner requests that an order be entered appointing me to be the”guardian of the person ”permanent guardian of [specify]:until the child reaches the age of ”18 ” 21 upon his/her consent,and that letters of guardianship issue. Form 6-1 Page 7 Dated: Signature of Petitioner Print or type name Signature of Attorney, if any Attorney’s Name (Print or Type) Attorney’s Address and Telephone NumberVERIFICATIONSTATE OF NEW YORK))ss.:COUNTY OF) ,being duly sworn, says that (s)he is the Petitioner in the above-namedproceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters therein statedto be alleged on information and belief and as to those matters (s)he believes it to be true.Sworn to before me thisday of . Petitioner (Deputy)Clerk of the Court Notary Public