Fill and Sign the Get the Fca1062 Form 10 11b Child Protective Affidavit in

F.C.A.§1062Form 10-11b(Child Protective- Affidavit inSupport of MotionTo Terminate Placement)(9/2006)FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF.......................................................................................In the Matter ofDocket No.CIN #A Child under Eighteen Years ofAge alleged to be AFFIDAVIT IN SUPPORT OF“Abused “Neglected byMOTION TOTERMINATE PLACEMENTRespondent(s).......................................................................................STATE OF NEW YORK ) ) SS.:COUNTY OF NEW YORK ), swears the following to be true under the penalties of perjury:1. I am the “parent “other interested person [specify relationship to child]: of [specify child]:.I am making this affidavit in support of the motion to terminate the child’s placement. 2.(Upon information and belief,) the above-named child, was removed from (his)(her) homeon [specify date]: and was placed in foster care on [specify date]: , as a result of a proceeding under Article 10 of the Family Court Act. Custody of the childremains with [specify]: 3. I made a request to [specify social services or agency official]: to terminate thechild’s placement and return the child to my home on [specify date]: . That request was “ denied on [specify date]: “ not granted within 30 days of my request. 4. The child’s placement should be terminated and the child should be returned to my home for the following reasons [specify]: Form 10-11b Page 25. No previous application has been made to any court or judge for this relief (except [specify]: ). WHEREFORE, I respectfully request that an Order be made herein terminating the placement ofthe above-named child, returning the child to my home and granting such other and further relief as theCourt may deem just and proper. AffiantSworn to before me this day of , (Deputy) Clerk of the CourtNotary Public