F.C.A §§651, 652, 654; D.R.L §240 General Form 18 (Order on Petition for Custody or Visitation) 8/2010 At a term of the Family Court of the State of New York held in and for the County of , at New York, on , PRESENT: Hon. Judge .............................................................................. In the Matter of a Proceeding for 9 Custody 9 Visitation under 9 Article 6 of the Family Court Act 9 Section 240 of the Domestic Relations Law Petitioner, Docket No. “ FINAL ORDER “ TEMPORARY ORDER ON PETITION FOR “ CUSTODY “ VISITATION against Respondent ................................................................................ NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY RESULT IN INCARCERATION FOR CRIMINAL CONTEMPT. The Petitioner herein having filed a petition on [specify date]: , , pursuant to 9 Article 6 of the Family Court Act 9 Section 240 of the Domestic Relations Law, requesting an order awarding “ custody “ visitation of the following minor children [list each child as follows]: Name of Child: Date of Birth: [Check applicable box(es)]: And the Respondent having Q been served Q not been served with a copy of the petition, Q been advised by the Court of the right to counsel, and having “ denied “ admitted the allegations of the petition, and having Q appeared Q not appeared before this Court to answer the petition and to show cause why an order of “ custody “ visitation should not be granted; Q And the Court having searched the statewide registry of orders of protection, the sex offender registry and the Family Court’s warrant and child protective records, and having notified the attorneys for the parties and for the child [check if applicable]: Q and the following self-represented party or parties [specify]: of the results of these searches; Q And the Court having considered and relied upon the following results of these searches in making this decision [specify; if no results found, so indicate]: [Applicable to TEMPORARY orders only where less than 90 days have elapsed since last record review]: Q And the Court, having dispensed with the search of the statewide registry of orders of American LegalNet, Inc. www.FormsWorkFlow.com General Form 18 Page 2 protection, the sex offender registry and the Family Court’s warrant and child protective records because these databases had been reviewed within the past 90 days; [Applicable where a party had made an allegation of domestic violence or child abuse; findings must be stated on the record, included in a written decision OR included in this order; check applicable box]: Q And the Court having explained its findings on alleged domestic violence or child abuse on the record; Q And the Court having issued a written decision containing its findings on alleged domestic violence or child abuse; Q And the Court having found that the allegation that [specify party]: had committed domestic violence or child abuse against [specify party or child(ren)]: Q was Q was not proven by a preponderance of the evidence, and having considered the effect of such domestic violence or child abuse upon the best interests of the child(ren) and relevant facts and circumstances as follows in making this order [specify how findings, facts and circumstances were factored into this Order]: And the matter having duly come on to be heard before this Court; NOW, after examination and inquiry into the facts and circumstances of the case and after hearing the proofs and testimony offered in relation thereto, this Court finds and determines that: [For modification cases: delete if inapplicable]:1 The following change of circumstances has occurred since the entry of the “order “judgment, dated [specify]: , awarding “custody “visitation [specify change in circumstance]: [Applicable to cases where Petitioner is a relative or other non-parent and where hearing was consolidated with child protective dispositional or permanency hearing, pursuant to F.C.A. §§1055-b or 1089-a; delete if inapplicable]: Termination of the order placing or remanding the child(ren) pursuant to Article 10 or 10-A of the Family Court Act Q will Qwill not not jeopardize the child(ren)’s safety and Q is Qis not in the best interests of the child(ren). The child(ren)’s birth mother Q has Q has not consented to the award of custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner’s standing to seek custody of the child(ren) [specify]: The child’s legally-established birth father Q has Q has not consented to the award of custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner’s standing to seek custody of the child(ren) [specify]: The child has been living with the following foster parent(s)[specify]: for a period in excess of one year, who G has/have G has/have not consented to the award of custody to the Petitioner. The local department of social services, the petitioner in the related Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award of custody to the Petitioner. 1 Form 40-a, the Order on Petition for Modification, may be used instead of this form in modification cases. American LegalNet, Inc. www.FormsWorkFlow.com General Form 18 Page 3 The attorney for the child(ren) [specify]: in the related Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award of custody to the Petitioner. And this Court further finds and determines that [specify]: And it is therefore ORDERED that the best interests of the above-named child or children require that [check applicable box(es)]: “custody “visitation be awarded as follows [specify]: ; and it is further [Applicable to cases involving a party or parties in the military; delete if inapplicable]: ORDERED that, since “ Petitioner “ Respondent is on active duty, deployed or temporarily assigned to military service and since such service affects such party’s ability to act as a joint or primary custodian of the child(ren), the return of such party from such active duty shall constitute a substantial change of circumstances sufficient to entitle such party to a review of this Order for possible modification if in the child(ren)’s best interests, unless the parties and child(ren)’s attorney have otherwise stipulated or agreed; and it is further ORDERED that during the period of active military service, deployment or temporary assignment, the party on such duty shall be permitted the following contact and visitation with the child [specify, including electronic communication and visitation during military leaves]: ; and it is further [Applicable to cases where hearing was consolidated with child protective dispositional or permanency hearing, pursuant to F.C.A. §§1055-b or 1089-a; delete if inapplicable]: ORDERED that the following local department of social services [specify]: and the following attorney for the child(ren)[specify]: shall be notified and shall be made parties to any subsequent proceedings for modification, enforcement or termination of the Order; and it is further [Applicable to temporary orders]: “ This Order shall expire [check applicable box]: “ on the following date [specify]: “ upon issuance of a further or final order in this case. AND IT IS FURTHER ORDERED that [specify]: ENTER Dated: Judge of the Family Court PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_ American LegalNet, Inc. www.FormsWorkFlow.com