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F.C.A. §1074 Form 10-15(Child Protective - Petition for Release Of ResponsibilityUnder Order of Placement)(9/2006)FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF............................................................................... In the Matter of Docket No. CIN # A Child under Eighteen Years of Age PETITION FOR RELEASE Alleged to be (Abused)(and)(Neglected) byOF RESPONSIBILITY UNDER ORDER OFPLACEMENT Respondent(s)..............................................................................NOTICE:IF YOUR CHILD IS PLACED IN FOSTER CARE, YOU MAY LOSE YOURRIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTEDWITHOUT YOUR CONSENT. IF YOUR CHILD STAYS IN FOSTER CARE FOR 15 OF THE MOSTRECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAW TOFILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS ANDMAY FILE BEFORE THE END OF THE 15-MONTH PERIOD. TO THE FAMILY COURT:The undersigned Petitioner respectfully alleges that:1. Petitioner isa duly authorized agency with its principal address at , New York.2. An Order of Placement was made on [specify date]:placing the above-named child with Petitioner pursuant to Article 10 of the Family Court Act.3. Petitioner requests that this Court release it from responsibility under the Order ofPlacement by reason of the following [specify]:4. No previous application has been made to any Court or judge for the relief requested Form 10-15 Page 2herein (except [specify]:)WHEREFORE, Petitioner requests an order granting Petitioner leave to return the childto the Court and releasing Petitioner from responsibility for the child and that a further Order ofDisposition with respect to the child be made in accordance with Article 10 of the Family CourtAct.Dated , .______________________________________Petitioner______________________________________Print or Type Name______________________________________Attorney, if any______________________________________Attorney’s Name (print or type)__________________________________________________________________________________________________________________Attorney’s Address and Telephone Number Form 10-15 Page 3VERIFICATIONSTATE OF NEW YORK ) )ss.:COUNTY OF) being duly sworn, deposes and says:That (s)he isand is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)hehas read the foregoing petition and knows the contents thereof; that the same is true to (his(her)own knowledge except as to those matters therein stated to be alleged upon information andbelief, and that as to those matters (s)he believes it to be true. PetitionerSworn to before me this day of____________________(Deputy)Clerk of the CourtNotary Public