Fill and Sign the Petition Termination of Parental Rights Parents Deceased Form

Soc. Serv. Law §§ 384-b, 384-c Form TPR-4 (Petition-Termination of Parental Rights – --Parents Deceased) (8/2010) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................................................ In the Matter of the Commitment of Docket No. Guardianship and Custody pursuant to §384-b of the Social Services Law of CIN # PETITION A Child under the Age of Eighteen Years, (Termination of Parental Rights Alleged to be Without a Living Parent --Parents Deceased) ......................................................................................... IF YOU ARE THE FOSTER PARENT OR CUSTODIAN OF THE CHILD, YOU HAVE A RIGHT TO HAVE A LAWYER REPRESENT YOU. IF YOU CANNOT AFFORD A LAWYER, YOU MAY ASK THE COURT TO APPOINT A LAWYER TO REPRESENT YOU WITHOUT FEE. TO THE FAMILY COURT: The undersigned Petitioner(s) respectfully alleges that: 1. Petitioner(s) , (is) (are) G an authorized agency having its office and place of business at [specify, including county]: G foster parent(s) residing at [specify, including county]: G child’s attorney G guardian ad litem filing at the Court’s direction, pursuant to Social Services Law §384-b(3)(b). 2 a. is a Gmale Gfemale child under the age of eighteen years, born on [specify]: , at [specify]: , who now resides at [specify, including county]: . b. The subject child ❑ is ❑ is not a Native-American child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicable box(es)]:❑ parent/custodian [specify name and give notification date]: ❑ tribe/nation [specify name and give notification date]: ❑ United States Secretary of the Interior [give notification date]: 3. (Upon information and belief) (B)(b)oth parents of the child are dead, and no guardian of the person of the child has been lawfully appointed. [Attach evidence in support of the allegation of the death of the parents.] Form TPR-4 page 2 4. The full name and last-known address of each parent and custodian of the child are: Name Last-Known Address 5. a. The name and last-known address of any other interested party who should be afforded notice of this proceeding are: Name Last-Known Address b. The name and last-known address of any other person entitled to notice of an adoption pursuant to Domestic Relations Law § 111-a are: Name Last-Known Address c. There are no persons other than those set forth entitled to notice of this proceeding or of an adoption of the child. 6. The child came into the care of , an authorized agency on the day of , , under the following circumstances: [include docket number, of child abuse, neglect or voluntary placement proceeding, if any] 7. The best interests of the child will be promoted by commitment of the guardianship and custody of the child to , Gan authorize agency Gfoster parent(s) for the following reasons: 8. The child ❑ is ❑is not under the jurisdiction of the Family Court. If so, this petition ❑ has ❑ has not been filed in the Court that exercised jurisdiction over the most recent permanency or other proceeding involving this child. [If it has not been so filed, petitioner must file affirmation, Form TPR-12]. 9. No previous application has been made to any court or judge for the relief sought herein (except ). WHEREFORE, Petitioner requests an order determining that the above-named child is a child whose parents are deceased and for whom no guardian has been lawfully appointed, and committing the guardianship and custody of the child to Gan authorized agency G foster parent(s), and for such other and further relief as in the interests of the child may be granted. Dated: ,. _______________________________________ GAgency GFoster parent (by Name __________________________________ Form TPR-4 page 3 Title ___________________________________) ________________________________________ Print or type name ________________________________________ Signature if Attorney, if any________________________________________ Attorney’s Name ( Print or Type)________________________________________________________________________________________________________________________ Attorney’s Address and telephone Number VERIFICATION STATE OF NEW YORK ) ) ss.: COUNTY OF ) , being duly sworn, says that (s)he is the Petitioner in the above-named proceeding and that the foregoing Petition 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 betrue. _____________________________________ Petitioner Sworn to before me this day of , _____________________________________ Notary Public