Fill and Sign the Form 3 4

F.C.A. §307.4Form 3-4 (Juvenile Delinquency - - Pre-petition Detention Application) 2/2001 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter ofDocket No. A Person Alleged to be aAPPLICATION - Juvenile Delinquent,PRE-PETITION DETENTION Respondent. TO THE FAMILY COURT: The undersigned, , is the [state title]: of , the agency responsible for operating a detention facility at , New York, and respectfully alleges that: 1.(Upon information and belief,) on [specify date]: , a child named , who lives at [specify address]: , New York, and who was born on [specify date]: was taken into custody by [specify]: for having allegedly committed the following delinquent act(s) [specify]: 2.(Upon information and belief,) the child was brought to this detention facility by [specify]: on [specify date]: 3.(Upon information and belief,) the child has not been released from this detention facility because [specify]: 4.(Upon information and belief,) this Court appears to have jurisdiction and the events occasioning the taking of the child into custody appear to involve acts constituting juvenile delinquency. 5.(Upon information and belief,) the child requires detention because [check applicable box(es) and state reasons]: Q there is a substantial probability that the child will not appear in court on the return date, based upon the following facts and for the following reasons Form 3-4 Page 2 [specify]: Q there is a serious risk that the child may before the return date commit an act which if committed by an adult would constitute a crime based upon the following facts and for the following reasons [specify]: 6. a. Continued placement in the Respondent’s home [check applicable box]: Q would Q would not be contrary to the Respondent\22s best interests, based upon the following facts and for the following specific reasons [specify]: This assertion is based upon the following specific documents and evidence: ? Probation Department report, dated [specify]: ? Mental health evaluation, dated [specify]: ? Other [specify]: ; AND b. Reasonable efforts, where appropriate and consistent with the need for protection of the community, to prevent or eliminate the need for removal of the Respondent from the home or, if the Respondent was removed prior to the date of the hearing, to return the Respondent safely to his or her home: Q were made as follows [specify reasonable efforts, including specific documents or evidence supporting findings]: Q were not made but the lack of efforts was appropriate [check all applicable boxes]: Q because of a prior judicial finding pursuant to Family Court Act §352.2(2)(c)that the authorized agency was not required to make reasonable efforts to reunify the Respondent with the Q parent(s) Q person(s) legally responsible [specify date of finding]: Q because [specify other reasons]: Q were not made. This asssertion is based upon the following specific documents and evidence: ? Probation Department report, dated [specify]: ? Mental health evaluation, dated [specify]: ? Other [specify]: 7.No previous application has been made to any court or judge for the relief requested herein (except [specify]: ). WHEREFORE, the undersigned requests that an order be made directing that the child, Form 3-4 Page 3 , be detained at , a facility for the detention of juveniles at , New York, pending the further order of the Court, and directing such other and further relief as to the Court may seem just and proper. Dated: (Agency) By: (Title) VERIFICATION (Agency) STATE OF NEW YORK ) ) ss.: COUNTY OF ) , being duly sworn, deposes and says: That (s) he 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 knows 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 , . Form 3-4 Page 4 (Deputy)(Clerk of Court) (Notary Public)