Fill and Sign the Form10 29a

F.C.A. §1034(2)Form10-29a(Child Protective-Application forOrder for Access to Child(ren) and/orHome-Before Petition Filed)(9/2006)FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF In the Matter ofDocket No.A Child(ren) Under the Age of EighteenAlleged to be APPLICATION FORAbused or Neglected byORDER FOR ACCESS TOCHILD(REN) AND/OR HOME-Before Petition FiledRespondent(s) TO THE FAMILY COURT:I, [specify name]: , having been duly sworn, state the following: 1. I am [ specify job title, agency and county]: 2. (Upon information and belief,) the child(ren) who are the subject(s) of this application is/are:Name Sex Date of Birth Custodial Parent/Guardian Child’s Address [Select Paragraph 3(a) OR 3(b) and check applicable boxes]: 3. “ a. Based upon the report of suspected child abuse or maltreatment, dated [specify]:and my subsequent investigation, I have reasonable cause to suspect that the life or health of thefollowing child(ren) [specify]: may be in danger. However,“ I have been unable to locate the above-named child or other children in the household; or“ On [specify date]: , I visited the child(ren)’s home at the address set forthin ¶1, but was denied access to the child (ren) sufficient to determine his/her/their safety; “ b. Based upon the report of suspected child abuse or maltreatment, dated [specify]:and my subsequent investigation, I have probable cause to believe that an abused or neglected child orchildren may be located at the address set forth in ¶1, but on [specify date]:I visited the child(ren)’s home at that address, but was denied access to the home to investigate; 4. On [specify date]: I advised [specify parent or other person legallyresponsible]: that, if access to the child and/or home, as applicableabove, was denied, I may seek an immediate court order for such access; Form 10-29a Page 2 5. [REQUIRED if application is made when the Family Court is not in session or if it islater than the Family Court’s deadline for new applications]: I would like to contact the FamilyCourt judge by telephone. I can be reached at [specify telephone number]:I am able to receive the Court’s order at [specify e-mail and/or fax number]: 6. No previous application has been made to any court or judge for the relief requested herein(except [specify]: ). WHEREFORE, for the reasons stated above, I am requesting that the Family Court issue anorder [check applicable box(es)]: [Applicable where paragraph 3(a) was selected]: “ requiring the parent or other person legally responsible to bring the following child or children[specify names]: “ immediately at any hour “ between the hours of 6AM and 9 PMfor observation and interviews outside the presence of the parent or other person legally responsible: “ to the following Child Advocacy Center [specify name and address]: “ to the following person for an interview and observation [specify name and address ofinterview/observation location]: “ to the Petitioner/Applicant for an interview and observation as follows [specify, includingaddress of interview/observation]: OR[Applicable where paragraph 3(b) was selected]: “ requiring the parent or other person legally responsible to permit me to enter the home “ immediately at any hour “ between the hours of 6AM and 9 PM , in order to: “ determine whether an abused or neglected child or children is/are present; “ conduct a home study to evaluate the home environment of the child or children;Dated: Signature of Applicant Print Name Title, Agency and County Sworn to before me this day of , (Deputy) Clerk of the CourtNotary Public