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F.C.A. §§355.3, 355.5Form 3-39(Juvenile Delinquency-Extension of Placement andPermanency Hearing Order) 12/2015At a term for the Family Court of theState of New York, held in and for theCounty ofat New Yorkon , .PRESENT Hon.Judge In the Matter ofDocket No.A Person Alleged to be aEXTENSION OFJuvenile Delinquent,PLACEMENT ANDPERMANENCY HEARINGRespondent.ORDER1 DEADLINE: IF THE RESPONDENT REMAINS IN A NON-SECURE LEVEL OF CARE, A PETITION FOR THE NEXT PERMANENCY HEARING MUST BE FILED NOT LATERTHAN [SPECIFY]:2 ________________________________ .The above-named Respondent having been adjudicated by this Court to be a juvenile1 NOTE: Delete “Permanency Hearing” if this is solely an extension of placement order. Utilize GeneralForm GF-35, instead of this form, if this is solely a permanency hearing order. Family Court Act §355.5(2) requiresthe permanency and extension of placement hearings to be combined. However, a permanency hearing may berequired in advance of (and thus separately from) an extension of placement if a finding is made that reasonableefforts are not required (requiring a permanency hearing within 30 days) or if the Respondent was placed on a felonypursuant to F.C.A. §353.3 for 18 months (requiring a permanency hearing annually). Further, if the Respondent isplaced in a facility not requiring a permanency hearing, an extension of placement hearing without a permanencyhearing may be held. Although all juveniles placed pursuant to Family Court Act §§353.3 and 353.5 are subject toextensions of placement, F.C.A. §355.5 requires a permanency hearing only with respect to juveniles who, duringthe period of placement, are or may be placed in a non-secure level of care, that is, in facilities with capacities of 25beds or fewer or are placed for re-placement with authorized agencies for foster or residential care.2 The petition must be filed at least 60 days prior to the date by which the hearing must be completed. SeeUniform Rules of the Family Court, 22 N.Y.C.R.R. §205.17(b). Family Court Act §355.5 requires a permanencyhearing regarding juveniles who are placed in non-secure facilities, although all juveniles placed pursuant to FamilyCourt Act §353.3 are subject to extensions of placement. See F.C.A. §355.3, 355.5. Form 3-39 Page 2delinquent within the meaning of Article 3 of the Family Court Act, and an Order of Disposition,dated [specify]: , having been issued placing Respondent with [check applicablebox]: “ a suitable person “ the New York State Office of Children and Family Services “ [Non-NYC cases]: the Commissioner of Social Services of [specify]: County, “ [NYC cases]: the Commissioner of the New York City Administration for Children’s ServicesAnd the petition of [specify]: , for anextension of placement and permanency hearing , sworn to on [specify date]: , having been filed in this Court [check applicable box]:“ at least 60 days prior to the expiration of the period of placement;“ less than 60 days prior to the expiration of the period of placement, and good cause having [check applicable box] “ been “ not been found for the delay; “ in the case of a placement of 12 months or more, at least 60 days prior to the date the permanency hearing must be held;“ in the case of a placement of 12 months or more, less than 60 days prior to the date the permanency hearing must be held, and good cause having [check applicable box] “ been “ not been found for the delay; And notice having been duly given to the following person(s), who appeared as follows:[specify; check applicable boxes]:“ Respondent “ with counsel “ without counsel “ Parent(s)[specify]:“ Other person(s) legally responsible for Respondent’s care [specify]: “ Prospective adoptive parent(s)[specify]:“ Foster parent(s)caring for Respondent [specify]: “ Relative(s) caring for Respondent [specify]: “ Authorized Agency caring for Respondent [specify]: “ Parents of siblings of the respondent [specify]: 3“ Other [specify]: And the matter having duly come on to be heard, and the above-named persons appearinghaving been given an opportunity to be heard, And the position and information provided by the [check applicable box(es)]: “ NYS Office of Children and Family Services “ [Non-NYC cases]: the Commissioner of Social Services of [specify]: County, “ [NYC cases]: the Commissioner of the New York City Administration for Children’s Serviceshaving been considered by the Court;3 Federal law [Public Law 113-183; 42 U.S.C. §675], requires permanency hearing notification to parentswho have legal custody of the respondent’s sibling or siblings. Siblings include those who would be siblings underNYS law, but for termination of parental rights or other disruption of parental rights, including death of a parent. Form 3-39 Page 3The Court, after having made an examination and inquiry into the facts and circumstancesof the case and into the surroundings, conditions, and capacities of the persons involved, finds anddetermines the following [Note: judicial findings must be made pursuant to both I and II,below]: I. Required “Best Interests” and “Reasonable Efforts” Findings [check applicable boxesand provide case-specific reasons in both A and B below]: A. “Best Interests” Finding: Return of the Respondent to the home “ would “ would not be contrary to the best interests of the Respondent because [specify facts and reasons]:This determination is based upon the following information [check applicable box(es)]:“ The Permanency Petition, dated [specify]:“ Probation Department report, dated [specify]:“ Mental health evaluation, dated [specify]:“ Uniform Case Record, dated [specify]:“ Risk Assessment Instrument“ Summary of the Uniform Case Record, dated [specify]:“ Service Plan, dated [specify]:“ The report of [specify]: , dated [specify]:“ Testimony of [specify]: “ Other [specify]: B. “Reasonable Efforts” Findings: 1. Reasonable efforts, where appropriate, to return the Respondent home safely [checkapplicable box and state reasons as indicated]: “ were made as follows [specify]:“ were not made but the lack of efforts was appropriate [check all applicable boxes]: “ because of a prior judicial finding pursuant to Family Court Act§352.2(2)(c)that the authorized agency was not required to make reasonableefforts to reunify the Respondent with the “ parent(s) “ person(s) legallyresponsible for Respondent’s care [specify date of finding]: “ because of other reasons [specify]:Q were not made.This determination is based upon the following information [check applicable box(es)]:“ The Permanency Petition, dated [specify]:“ Probation Department report, dated [specify]: Form 3-39 Page 4“ Mental health evaluation, dated [specify]:“ Uniform Case Record, dated [specify]:“ Risk Assessment Instrument“ Summary of the Uniform Case Record, dated [specify]:“ Service Plan, dated [specify]:“ The report of [specify]: , dated [specify]:“ Testimony of [specify]: “ Other [specify]: 2. [Required in cases in which the Respondent’s permanency plan is adoption, guardianship orpermanent living arrangement other than reunification]: Reasonable efforts to make and finalize thepermanency plan of [specify]: “ were made as follows [specify]: “ were not made based upon the following facts and for the following reasons [specify; if lackof efforts was reasonable, so indicate]: This determination is based upon the following information [check applicable box(es)]:“ The Permanency Petition, dated [specify]:“ Probation Department report, dated [specify]:“ Mental health evaluation, dated [specify]:“ Uniform Case Record, dated [specify]:“ Risk Assessment Instrument“ Summary of the Uniform Case Record, dated [specify]:“ Service Plan, dated [specify]:“ The report of [specify]: , dated [specify]:“ Testimony of [specify]: “ Other [specify]: II. Required Findings Regarding Program Services, Transitional Services and Out-of-StatePlacements:A. Required for Respondents 16 years of age or older with Alternative PlannedPermanent Living Arrangement (APPLA) Goals [check applicable box(es)]: 1. “ Evidence “ has “ has not been provided to the Court that a “reasonable andprudent parent” standard of care has been applied to Respondent in the facility or home in whichhe or she resides; 2. “ Evidence “ has “ has not been provided to the Court that Respondent has beenprovided with regular, ongoing opportunities to engage in age or developmentally appropriateactivities and has been consulted in an age-appropriate manner about the opportunities to participate in such activities; 3. “ Evidence “ has “ has not been provided to the Court, indicating compelling Form 3-39 Page 5reason(s) that it would not be in the Respondent’s best interests to return home, be referred for termination of parental rights and adoption, placed with a fit and willing relative, or placed witha legal guardian. These reasons are as follows [specify compelling reason(s)]:4. “ Evidence “ has “ has not been provided to the Court, indicating that intensive,ongoing, and, as of the date of this petition, unsuccessful efforts were made to return theRespondent home or secure a placement for the Respondent with a fit and willing relative,including adult siblings, a legal guardian, or an adoptive parent, including through efforts that utilize search technology including social media to find biological family members ofRespondent.5. The Court inquired directly of the Respondent regarding the permanency plan. 6. The following individual, with whom Respondent has a significant connection, iswilling and is designated to be the Respondent’s permanency resource [specify]:7. The Court has determined that APPLA with a significant connection to an adult willingto be a permanency resource for the Respondent is the best permanency plan for the Respondentbecause [specify]: B. “ [Required where Respondent is 14 years of age or older]: The services, if any, needed to assist the Respondent to make the transition from foster care to independent living are[specify]:C. “ [Required where the Respondent is placed outside New York State]: Placementoutside New York State “ is “ is not appropriate and in the Respondent’s best interests; NOW, after examination and inquiry into the facts and circumstances and afterhearing the proof and testimony, it is thereforeA. Temporary Order Extending Placement“ ORDERED that, probable cause having been found for continuing the placementtemporarily pending the hearing and that such temporary order is necessary, Respondent’splacement is extended until [specify date not to exceed 30 days]:44 The permanency hearing (required for Respondents placed in non-secure facilities, as defined by F.C.A.§355.5(1), residential care or foster homes) must be held and the “best interests” and “reasonable efforts” findings Form 3-39 Page 6B. Extension of Placement: Disposition of Petition (Required)“ ORDERED that the petition is GRANTED and the placement is extended to thefollowing date [specify]: , subject to further orders of this Court.“ ORDERED that the petition is DISMISSED and the Respondent is discharged from thecustody of [specify]: on [specify date no later than the date of expirationof the placement period]:C. Permanency Plan (Required where permanency hearing was held under F.C.A. §355.5)5 ORDERED that Petitioner’s permanency plan for the above-named Respondent [checkapplicable box]: “ is approved “ is modified, as follows [check applicable box(es) and indicate time frame(s)]:“ reunification with the “ parent(s) “ person(s) legally responsible for Respondent’s care by [specify date]:“ placement for adoption upon filing of a petition to terminate parental rights by [specify date]: “ referral for legal guardianship by [specify name and date]:“ permanent placement with the following fit and willing relative [specify name]: by [specify date]:.“ [Applicable ONLY to Respondents who are 16 years of age or older]: permanentplacement in the following alternative permanent planned living arrangement [specify]: D. Reasonable Efforts (Applicable where permanency hearing held under F.C.A. §355.5)6 [Optional in cases in which the Respondent’s goal is reunification with the parent or guardian;check box if applicable]:“ ORDERED that following reasonable efforts shall be made to make and finalize theRespondent’s goal of reunification [specify]: above must be made on a timely basis, even if the placement is extended only temporarily. One or more temporaryextension of up to 30 days may be granted only upon satisfactory proof of probable cause and the necessity of eachorder. F.C.A. §355.3(5) provides that “[t]he court may order additional temporary extensions, not to exceed a total of15 days, if the court is unable to conclude the hearing within the 30 day temporary extension period. In no event shallthe aggregate number of days in extensions granted or ordered under this subdivision total more than 45 days. Thepetition shall be dismissed if a decision is not rendered within the period of placement or any temporary extensionthereof.” 5 See Note 1.6 See Note 1. Form 3-39 Page 7; (and it is further)[Optional in cases in which the Respondent’s goal is adoption, guardianship or permanent livingarrangement other than reunification; check box if applicable]:“ ORDERED that following reasonable efforts shall be made to make and finalize theRespondent’s goal of [specify goal and describe efforts]:; (and it is further)E. Service Plan (REQUIRED where permanency hearing held under F.C.A. §355.5)7 “ ORDERED that the service plan submitted by the Petitioner [check applicable box]:“ is appropriate “ should be modified as follows [specify]:;and shall be given by Petitioner, along with a copy of this Order; to the [check applicable box]: “ parent(s) “ person(s) legally responsible for the Respondent’s care, ; (and it is further)F. Transitional Services [check applicable box(es)]: [Applicable in cases where the Respondent is 14 years of age or older]:“ ORDERED that the Petitioner is directed to provide the following services determinedabove to be needed to assist the Respondent to make the transition from foster care to independentliving [specify]: ; (and it is further) [REQUIRED where release plan has been submitted pursuant to Family Court Act §353.3(7) ]:“ ORDERED that the plan for the Respondent’s “ release “ conditional release is[check applicable box]: “ approved “ modified as follows [specify]: 8 ; (and it is further)“ ORDERED that Petitioner shall take the following steps to implement the plan for theRespondent’s “ release “ conditional release [specify]:[Required where placement is extended and release plan has not yet been submitted]: “ ORDERED that 30 days prior to the conclusion of the placement or, if an extension ofplacement will be sought, 60 days prior to the date by which a permanency hearing must beconcluded, Petitioner shall submit a report to the Court, attorney for the child or attorney of record7 See Note 1.8 See Family Court Act §353.3(7). Form 3-39 Page 8and Presentment Agency containing a plan for the release or conditional release of theRespondent in accordance with section 353.3(7) of the Family Court Act; (and it is further)G. Out-of-State Placement [REQUIRED where Respondent has been placed out-of-state]: “ ORDERED that the placement of the Respondent at [specify]: “ is appropriate and in the Respondent’s best interests and is continued until [specify]:“ is not appropriate and in the Respondent’s best interests and the Respondent shall, therefore, bereturned to New York State to be : “ placed with [specify]: until [specify]: “ discharged to [specify]: ; (and it is further)H. Reports, Notices, Visitation Plans and Services [check box(es) if applicable]:“ ORDERED that Petitioner shall make a progress report to the Court, the parties and theattorney for the child on the implementation of this order not later than 90 days from the date ofthis order and every [specify period]: days thereafter; (and it is further)“ ORDERED that if the above permanency plan for the Respondent is changed, noticeshall be provided to the Court, the parties and the attorney for the child forthwith; (and it isfurther)“ ORDERED that the “ parent(s) “ person(s) legally responsible for Respondent’scare be notified of the planning conference(s) to be held and of (his)(her)right to attend suchconference(s) with counsel or other person; (and it is further)“ ORDERED that Petitioner shall provide the “ parent(s) “ person(s) legallyresponsible for Respondent’s care with visitation with the Respondent as follows [describevisitation plan]: ; (and it is further)“ ORDERED that Petitioner shall provide the following sibling(s) [specify]: with visitation with the Respondent as follows [describe visitation plan]:; (and it is further)[NYC cases only; applicable where Respondent is placed with the NYC Administration forChildren’s Services for non-secure or limited-secure level of care where specific servicesare needed]: “ The Commissioner of the New York City Administration for Children’s Services is Form 3-39 Page 9directed to provide the following services, authorized or required to be made available in theapproved plan for the “Close to Home” program, to meet the needs of the Respondent [specifyservices; note: if the Respondent has been found to be sexually exploited, as defined in SocialServices Law §447-a, so indicate if Respondent needs the services afforded by an available long-term safe house]:[Required where Respondent is placed with the New York City Administration forChildren’s Services; optional for all other placement cases; check box if applicable]: “ The placement agency is directed to provide prior notice to the Respondent, attorney forthe Respondent and Respondent’s parent or guardian in the event that Respondent is transferredfrom one facility to another, unless an immediate change of placement is necessary, in which casethe notice shall be transmitted on the next business day.I. Deadline for Filing Next Permanency Petition (Required if permanency hearing held pursuant to F.C.A. §355.5)9 ORDERED that if the Respondent remains in foster care, Petitioner shall file apetition for the next permanency hearing NO LATER THAN [specify date not less than 60days before deadline for completion of hearing]: and the permanency hearing shall be completed by [specify date]: and it is furtherORDERED, that . ENTERED Judge of the Family CourtDated:PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACTAN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT,35 DAYS FROM THE DATE OF MAILING OF THE ORDER TOAPPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTERSERVICE 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]: 9 See Note 1.