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F.C.A. §322.1 Form 3-24 (Juvenile Delinquency- Modificationof Order of Commitment) 6/2016 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ------------------------------------------------------------------- In the Matter of Docket No. PETITION A Person Alleged to be (Modification of Order of Commitment) Juvenile Delinquent, Respondent. -------------------------------------------------------------------TO THE FAMILY COURT: The undersigned, appearing on behalf of the Petitioner, respe ctfully alleges that: 1. (a) Petitioner is ” the Commissioner of Mental Health ” the Commissioner of the Office of People with Developmental Disabilities ” related to Respondent in the above- entitled proceeding as follows [specify]: and is appearing on behalf of the Respondent for the purpose of filing this petition. (b) Respondent has been committed to a residential facility within the appropriate office of the Office of Mental Hygiene. 2.Petitioner believes that the continued commitment of the above-named child in such residential facility is no longer appropriate in that [ sp ecify]: WHEREFORE, Petitioner requests a hearing for a modification of the order of commitment, dated , to authorize the transfer of Respondent to a non-residential facility. Dated: _________________________ Commissioner By_______________________ Name _________________________ Title OR By_____________________________ Person Appearing on Behalf of the Respondent VERIFICATION Form 3-24 Page 2 (Agency) STATE OF NEW YORK ) ) ss.: COUNTY OF_______________________ ) _________________________________________ , being duly sworn, deposes and says: That (s)h e is the_______________________ _______ of ____________________, an agency authorized to originate the above- entitled proceeding, and is acquainted with the facts and circumstances therein; that (s)he has read the foregoing and kn ows the contents thereof; that the same is true to (his) (her) own knowledge , except as to matters therein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. _____________________________ Name_____________________________ Title Sworn to before me this _____ day of _________________, _____ . ________________________________________ Notary Public VERIFICATION (Individual) STATE OF NEW YORK ) ) ss.: COUNTY OF_____________________ ) _______________________________________ ______, being duly sworn, deposes and says: That (s)h e is the________________________ __________________________ in the above-entitled proceeding 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) own knowledge, except as to matters therein stated to b e alleged on information and belief and as to those matters (s)he believes it to be true. _____________________________ Sworn to before me this _____ day of _____________, _____ . _________________________________ (Deputy) (Clerk of the Court) (Notary Public)