F.C.A. §§ 651, 652 General Form GF-40 (Petition for Modification of Order of Custody or Visitation ­Family or Supreme Court) 1 12/2015 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .................................................................................... In the Matter of a Proceeding for Custody/Visitation Under Article 6 of the Family Court Act Docket No. Petitioner, PETITION FOR MODIFICATION OF ORDER OF Custody Visitation MADE BY FAMILY COURT SUPREME COURT -againstRespondent ....................................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully shows that: 1. I am [specify relationship to child(ren)]: of [specify child(ren)'s name(s)]: I am seeking to modify an order of [check applicable box(es)]: custody visitation. 2. The home addresses of the Petitioner and Respondent are as follows:2 Petitioner: Respondent: 3. Petitioner is Supreme Court of the State of New York, Family Court of the State of New York, entitled and was the in an action filed in County, Index No. [specify]: County, Docket No. [specify]: 4. [Applicable when Petitioner and/or Respondent are on active duty or have recently returned from active military service; DELETE if inapplicable]: a. Petitioner [check applicable box]: is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is 1 If the order was entered by a Court outside New York State or a tribal court, use Form UCCJEA-9. Unless ordered confidential, pursuant to Family Court Act §154-b, because disclosure would pose an unreasonable risk to he health or safety of the party . See Forms GF-21 and 21a, available at www.nycourts.gov. American LegalNet, Inc. www.FormsWorkFlow.com 2 General Form GF-40 likely to affect custody or visitation, if at all]:3 Page 2 returned from active duty, deployment or temporarily assignment to military service as follows [specify date of return, type of service, military branch or National Guard unit, anticipated dates and location of duty and how return from active duty is likely to affect custody or visitation, if at all]: b. Respondent [check applicable box]: is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]:4 returned from active duty, deployment or temporarily assignment to military service as follows [specify date of return, type of service, military branch or National Guard unit, anticipated dates and location of duty and how return from active duty is likely to affect custody or visitation, if at all]: the 5. a. A judgment order, dated Respondent Petitioner to [specify terms]: judgment , was entered in the action directing A true copy of the . order is attached and made a part of this Petition. b. [Applicable where the judgment or order had been entered in conjunction with a child protective dispositional or permanency hearing order directing custody with a relative or other non-parent, pursuant to Family Court Act §1055-b or §1089-a; delete if inapplicable]: (i) The judgment order was issued in conjunction with the following child protective or permanency proceeding [specify Family Court, county and docket #]: (ii) The judgment order provided that the following local department of social services [specify]: and the following attorney for the child(ren)[specify]: must be notified and shall be made parties to any subsequent proceedings for modification, enforcement or termination of the judgment or order. 6. The names, addresses and dates of birth of all children affected by this order are: Address5 Date of Birth Name 3 Inapplicable if Petitioner is based at a permanent duty station or has had a permanent reassignment of station. 4 Inapplicable if Respondent is based at a permanent duty station or has had a permanent reassignment of station. Unless ordered confidential, pursuant to Family Court Act §154-b, because disclosure would pose an unreasonable risk to he health or safety of the party . See Forms GF-21 and 21a, available at www.nycourts.gov. American LegalNet, Inc. www.FormsWorkFlow.com 5 General Form GF-40 Page 3 7. [Applicable where Order or judgment had been issued by Supreme Court; delete if inapplicable]: Under the terms of the judgment order , the Supreme Court has not retained exclusive jurisdiction to modify the judgment order . 8. (Upon information and belief) Since the entry of the change of circumstances in that [specify]: judgment order, there has been a 9. Because of this change of circumstances, the follows [specify]: judgment order should be modified as 10. [Applicable to cases in which petitioner is a relative or other non-parent seeking to modify a custody order and where a child protective petition or permanency hearing report has been filed regarding the children; delete if inapplicable]: a. A child protective petition, Docket # [specify]: , was filed in Family Court, [specify county]: on [specify date]: alleging that [specify names of respondents on that petition]: neglected or abused the above-named child(ren). The petition resulted in [specify whether finding was made and, if so, the disposition; if the disposition has been adjourned pending a consolidated hearing with this petition, pursuant to F.C.A. §1055-b, so indicate and give next court date]: b. A permanency report, Docket # [specify]: , pursuant to Article 10-A of the Family Court Act, was filed in Family Court, [specify county]: on [specify date]: indicating a permanency plan of custody of the child(ren) with Petitioner in this proceeding. The permanency hearing was adjourned to [specify date]: pending a consolidated hearing with this custody modification petition, pursuant to F.C.A. §1089-a. c. The child's birth mother has has not consented to the modification of the custody order to award custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner's standing to seek custody of the child(ren) [specify]: d. The child's legally-established birth father has has not consented to the modification of the custody order to award custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner's standing to seek custody of the child(ren) [spe