Fill and Sign the Petition for Form

D.R.L.§115-c; S.C.P.A.§1725Form 21-A(Petition forTemporary Guardianship) 9/2008FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF.........................................................................................In the Matter of the TemporaryGuardianship of A Child Whose (Docket)(File)No.First Name isPetition for TemporaryGuardianship.......................................................................................... The Petitioner(s) respectfully allege(s) to the Court that: 1. Physical custody of [specify child’s first and last name]: , a child born on , was transferred to [specify]: and for the purposes of adoption on the day of , by [specify]: , the child's “parent(s) “guardian(s), and the requirements for certification of [specify]: as qualified adoptive parents herein were [check applicable box]: “ complied with “ duly waived by order of the , Court, County of dated 2. The residence and telephone number of Petitioner(s) are: 3. The full name(s) and addresse(s) of the birth parent(s) of the child are:. 4. The anticipated name of the child subsequent to adoption will be: . 5. The anticipated residence of the child subsequent to adoption will be: Form 21-A page 2 6. A consent to the adoption of the child was duly executed pursuant to section 115-b of theDomestic Relations Law on , . A copy of the consent to the adoptionis annexed hereto. 7. The child will be residing with Petitioner(s), and a petition for adoption of the child byPetitioner(s) will be filed in the Court of the County of , State of New York, within 45 days of the execution of the consent toadoption of the child. 8. No previous petition has been filed or application made to any court or judge for therelief sought herein (except)[include any proceedings dismissed or withdrawn]: WHEREFORE, Petitioner(s) request(s) an order granting temporary guardianship of thechild to Petitioner(s). Petitioner(s)________________________________ Applicant________________________________Print or type name________________________________Signature of Attorney, if any________________________________Attorney’s Name (Print or Type)________________________________________________________________________________________________Attorney’s Address and Telephone NumberDated: Form 21-A page 3 VERIFICATIONSTATE OF NEW YORK))ss.:COUNTY OF) , being duly sworn, saysthat (he) (she) (they) (is)(are) the Petitioner(s) in the above-named proceeding and that theforegoing petition is true to (his) (her) (their) own knowledge, except as to matters thereinstated to be alleged on information and belief, and as to those matters (he)(she)(they) believe(s)it to be true. Petitioner(s)Subscribed and sworn to before methis day of , . (Deputy) Clerk of the CourtNotary Public