Soc. Serv. Law §§ 358-a, 384-a, 384-c Form 358-a-5 (Order of Disposition - Petition for Approval of an Instrument) 8/2010 At a term of the Family Court of then State of New York, held in and for the County of , at , New York , on P R E S E N T: Hon. Judge ____________________________________________ In the Matter of the Application for Approval of an Instrument concerning Docket No. ORDER OF DISPOSITION-PETITION FOR APPROVAL OF AN INSTRUMENT CIN # Pursuant to Section 358-a of the Social Services Law _____________________________________________ NOTICE: 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. IF THE PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. THE NEXT PERMANENCY HEARING SHALL BE HELD ON [SPECIFY DATE/TIME]:1 The Petition of an authorized official of the G Department of Social Services for [specify]: County, G New York City Administration for Children's Services, dated [specify]: , having been filed with the Court requesting approval of an instrument transferring custody and care of the child to the agency; And the following person(s) having been duly served with notice of this proceeding and having been given an opportunity to be heard [check applicable boxes]: Parent [specify]:: having appeared with counsel without counsel waived counsel not appeared; Parent [specify]:: having appeared with counsel without counsel waived counsel not appeared; Guardian(s) [specify]: Appeared: yes no with counsel without counsel Specify a date certain not more than eight months from the date of removal. If the child has a sibling or half-sibling removed from the home, whose permanency hearing is scheduled before this Court, the date certain shall be the same as the date certain for the sibling's or half-sibling's permanency hearing, unless the sibling or halfsibling was removed on a juvenile delinquency or PINS petition or unless he or she has permanency hearing shall be cancelled. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 358-a-5 Petitioner Appeared: yes no Prospective adoptive parent(s) [specify]: Relatives providing care for the child [specify]: Other [specify]: Appeared: yes no Appeared: yes no Page 2 Appeared: yes no with counsel without counsel; And the parent(s) [specify]: guardian(s)[specify]: having by written instrument consented to the jurisdiction of this Court and waived service of the petition and notice of proceeding, and the Court having dispensed with such service [check box(es) if applicable]; And an attorney having been appointed and having appeared to represent the child; [Required in cases involving Native-American children; check if applicable ]: And the following having been duly notified [check applicable box(es)]: parent/custodian tribe/nation United States Secretary of the Interior; And the tribe/nation having: appeared and participated as a party; appeared and declined to assume jurisdiction; appeared and requested transfer of jurisdiction; not appeared; [Note: Required; judicial findings must be made pursuant to I and, if petition is GRANTED, II , III and, if applicable, IV]: And the matter having duly come on for a hearing before this Court, the Court, after hearing the proof and testimony offered in relation to the case, finds and determines that: I. Criteria for Approval of Placement Instrument [Check applicable box(es) in A, B and C, below]: A. The parent(s) [specify]: guardian(s) [specify]: did did not execute such instrument knowingly and voluntarily; and B. The parent(s) [specify]: guardian(s) [specify]: would would not be able to make adequate provision for the care, maintenance and supervision of the child in the home; and C. The requirements of Social Services Law §384-a have been satisfied (except [specify] ). II. "Best Interests" and "Reasonable Efforts" Findings [check applicable boxes and provide casespecific reasons in A, B and C, below] A. Continuation of the child in, or return of the child to, the child's home would be contrary to the best interests of the child because [specify facts and reasons]: This determination is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: , dated [specify]: American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-5 G Other [specify]: Page 3 B. Reasonable efforts, where appropriate, to prevent or eliminate the need for placement, and, if the child was removed prior to the date of the hearing, to return the child home safely [check applicable box and state reasons as indicated]: G were made as follows [specify]: G were not made but the lack of efforts was appropriate [check all applicable boxes]: G because of a prior judicial finding that the authorized agency was not required to make reasonable efforts to reunify the child with the G parent(s) G guardian(s) [specify date of finding]: G because [specify other reasons]: G were not made. This determination is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: C . [REQUIRED in cases in which the child's permanency plan is adoption, guardianship or permanent living arrangement other than reunification]: Reasonable efforts to make and finalize the permanency plan of [specify]: G were made as follows [specify]: G were not made. This determination is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: , dated [specify]: G Other [specify]: III. Findings Regarding Relatives and Siblings [Required; check applicable boxes in A and B, below]: A. Relatives: Based upon the investigation conducted by the Commissioner of Social Services, [Check applicable box(es]: G The following person is a suitable person related to the child with whom such child may appropriately reside [specify]: Such person: G seeks approval as a foster parent in order to provide care for the child; G wishes to provide care and custody for the child without foster care subsidy at this time. may be a resource but not yet determined whether as foster parent or custodian. G There is no suitable person related to the c