Fill and Sign the Ssl383 C 384 384 C Form Surr 1 Surrender Notice

Soc. Serv. Law §§ 383-c, 384 Form SURR-3 (Petition for Approval of Extra- Judicial Surrender Instrument) (9/2006) FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF......................................................................................... In the Matter of the Application for Docket No. Approval of a Surrender Instrument Concerning PETITION FO R APPROVAL OF EXTRA-JUDICIAL Child’s Name: SURRENDER INSTRUMENT Date of Birth: CIN #Pursuant to Section G 383-c G 384 of the Social Services Law ........................................................................................ TO THE FAMILY COURT OF THE COUNTY OF : The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner, [specify]: , is an authorized agency having its office and place of business at [specify]: in the County of [specify]: , State of New York. 2. a.. The child, [specify]: , is a [check applicable box]: G male G female child under the age of eighteen years, born on [specify date]: at [specify]: , who now resides in the County of [specify]: , State of New York. 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. a. The child is now in the custody of the Petitioner and resides with [specify, unless confidential]: b. [Applicable to surrenders pursuant to Social Services Law §383-c]: The child entered foster care on [specify]: as a result of [specify proceeding, docket number court and status]: The most recent permanency hearing was held in [check applicable box]: G this Court G another Court [specify]: on [specify date]: 4. The guardianship of the person and custody of the child have been committed to the Petitioner by a written instrument of surrender, signed on [specify date]: by [check applicable box(es)]: a. G mother [specify]: Form SURR-3 Page 2 b. G father [specify]: [Applicable if surrender executed by father]: Paternity was established by [check applicable box; if not established, so state]: G Marriage between the above-named parents. G An order of filiation entered on [specify date and court]: G An acknowledgment of paternity signed on [specify date]: c. G legal guardian [specify]: 5. [Applicable if surrender was executed by one parent or by legal guardian]: The child’s parent or parent(s), other than the parent(s) who executed the surrender, is or are as follows [check applicable box(es)]: a. G The child’s mother [specify]: G retains parental rights to the child. G is or was the subject of the following child abuse, child neglect, foster care placement or review and/or child custody proceeding(s) [specify type of proceeding, court, docket number, date filed, final disposition or order, if any, and current status of proceeding, if available]: G surrendered the child on [specify date]: G is the subject of a pending surrender proceeding [specify date filed, court and status]: G had her rights to the child terminated on [specify date]: G is the subject of a pending termination of parental rights proceeding [specify date filed, court and status]: G is deceased G is unknown. b. 9 The child’s father is [specify]: 1). Paternity was established by [check applicable box; if not established, so state]: G Marriage between the above-named parents. G An order of filiation entered on [specify date and court]: G An acknowledgment of paternity signed on [specify date]: 2). The child’s father [specify]:G retains parental rights to the child. G is or was the subject of the following child abuse, child neglect, foster care placement or review and/or child custody proceeding(s) [specify type of proceeding, court, docket number, date filed, final disposition or order, if any, and current status of proceeding, if available]: G surrendered the child on [specify date]: G is the subject of a pending surrender proceeding [specify date filed, court and status]: G had his rights to the child terminated on [specify date]: G is the subject of a pending termination of parental rights proceeding [specify date filed, court and status]: Form SURR-3 Page 3 One witness must be an employee of the authorized agency trained to receive surrenders and one witness 1 must be an attorney or certified social worker not employed by and independent of the authorized agency. See Social Services Law §383-c(4). If the employee responsible for arranging for supportive counseling is the same employee who witnessed 2 the surrender, a combined affidavit (Form SURR-4) may be submitted. G is deceased. G is unknown. 6. In addition to the above-named child’s parent(s) or guardian(s), the following individuals must be notified of this proceeding, pursuant to Social Services Law §384- c [specify]: Name Address [unless confidential] Relationship There are no persons other than those set forth above entitled to notice pursuant to Section 384-c of the Social Services Law. 7. a. [Applicable to surrender of child in foster care]: The instrument of surrender was executed and acknowledged before [specify at least two witness(es)]: , whose affidavit(s) (is)(are) attached to, and made a part of, this petition. 1 b. [Applicable to surrender of child not in foster care]: The instrument of surrender was executed and acknowledged before [specify at least one witness]: 8. [Applicable to surrender of child in foster care; check applicable box(es)]: a. Supportive counseling for the person executing the surrender was 9 offered 9 arranged by [specify]: , an employee of the following authorized agency [specify]: , whose affidavit is attached to, and made a part of, this petition. 2 b. Supportive counseling for the person executing the surrender was: G provided by [specify]: , whose affidavit is attached to, and made part of, this petition. The counseling was provided on [specify date]: as follows [specify]:G not provided because: G the offer of counseling was rejected by the person executing the surrender G other reason [specify]: 9. a. The surrender is subject to the following condition(s)[specify]: b. [Applicable where surrender is subject to condition of adoption by s pecific individual]: The surrender is conditional upon adoption by [specify]: , who, in accordance with regulations of the NYS Office of Children and Family Services, has been [check applicable box(es)]: G investigated and approved as a prospective adoptive parent G certified or approved as a foster parent c. [Applicable where post-adoption contact agreement has been signed]: The annexed post- adoption contact agreement is in the child’s best interests for the followin g reasons [specify]: The agreement has been consented to in writing by the following [specify]: Form SURR-3 Page 4 Include a separate paragraph for each person who executed the surrender. 3 Adoptive parent(s)[specify]: Birth parent(s) [specify]: Adoptive child’s Law guardian [specify]: Sibling(s) or half-sibling(s) over the age of 14, if contact is with siblin gs or half-siblings [specify]: 10. The parent or guardian who executed the surrender [check applica ble box]: G signed 3 G did not sign a written statement included in or appended to the surrender instrument waiving written notice of any substantial failure of a material condition. 11. No previous application has been made for the approval of this instrument of surrender to any court of judge, except [specify; delete if inapplicable]: . WHEREFORE, Petitioner requests that this Court enter an order approving the surrender instrument on such notice to such persons as the Court may in its discretion provide [delete if inapplicable]: and approving the attached post-adoption contact agreement, and granting such other and further relief as this Court deems just and proper. Petitioner Print or type name Signature of Attorney, if any Attorney’s Name (Print or Type) Attorney’s Address and Telephone # VERIFICATION STATE OF NEW YORK ) )SS.: COUNTY OF ) ,being duly sworn, deposes and says: That (s)he is and is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)he has 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 st ated to be alleged upon information and belief, and that as to those matters (s)he believes it to be true. Petitioner Sworn to before me this day of , . (Deputy) Clerk of the Court (Notary Public)