F.C.A. §1074 Form 10-15 (Child Protective - Petition for Release Of Responsibility Under Order of Placement) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................... In the Matter of Docket No. CIN # A Child under Eighteen Years of Age Alleged to be (Abused)(and)(Neglected) by PETITION FOR RELEASE OF RESPONSIBILITY UNDER ORDER OF PLACEMENT Respondent(s) .............................................................................. NOTICE: IF YOUR CHILD IS PLACED IN FOSTER CARE, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. IF YOUR CHILD STAYS IN FOSTER CARE FOR 15 OF THE MOST RECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAW TO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END OF THE 15-MONTH PERIOD. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner is a 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 of Placement by reason of the following [specify]: 4. No previous application has been made to any Court or judge for the relief requested American LegalNet, Inc. www.FormsWorkflow.com Form 10-15 herein (except [specify]: Page 2 ) WHEREFORE, Petitioner requests an order granting Petitioner leave to return the child to the Court and releasing Petitioner from responsibility for the child and that a further Order of Disposition with respect to the child be made in accordance with Article 10 of the Family Court Act. Dated , . ______________________________________ Petitioner ______________________________________ Print or Type Name ______________________________________ Attorney, if any ______________________________________ Attorney's Name (print or type) ______________________________________ ______________________________________ ______________________________________ Attorney's Address and Telephone Number American LegalNet, Inc. www.FormsWorkflow.com Form 10-15 VERIFICATION Page 3 STATE OF NEW YORK COUNTY OF ) )ss.: ) 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 stated 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 American LegalNet, Inc. www.FormsWorkflow.com