F.C.A. § 1089 Soc. Serv. Law §384-b Form TPR-5 (Findings of Fact, Conclusions of Law and Order of DispositionParents Deceased) 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 ,. P R E S E N T: Hon. Judge _______________________________________ In the Matter of a Commitment of Guardianship and Custody pursuant to §384-b of the Social Services Law of Docket No. FINDINGS OF FACT, CONCLUSIONS OF LAW AND ORDER OF DISPOSITION (Parents Deceased) CIN # A Child under the Age of Eighteen Years, Alleged to be a Permanently Neglected Child ______________________________________ THE NEXT PERMANENCY HEARING SHALL BE HELD ON [specify date/time]:1 ______________________________________ A Petition under Section 384-b of the Social Services Law having been filed alleging that the parent(s) of the above-named child (is)(are) deceased; and summonses having been issued and duly served upon and notice having been duly given to all proper parties hereto, and And [specify]: having appeared before the Court; and the child having been represented by an attorney; [Required in cases involving Native-American children; check if applicable]: And the following having been duly notified [check applicable box(es)]: 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; And the matter having duly come on for a fact-finding hearing , the Court, after hearing the proofs and the testimony offered in relation to the case, finds upon clear and convincing evidence that the abovenamed child has no living parent or anyone else entitled to consent to an adoption; and 1 W here custody and guardianship of the child are transferred, the permanency hearing must be scheduled for a date certain within 30 days of the earlier of this Court's announcement of its decision or issuance of this Order. The next permanency hearing must be scheduled for a date certain not more than six months after the completion of the permanency hearing. A separate permanency order, Form PH-6, must be issued even if the permanency hearing is combined with the dispositional hearing in this proceeding. American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-5 Page 2 makes the following findings of fact by clear and convincing evidence and comes to the following conclusions of law: FINDINGS OF FACT [insert] CONCLUSIONS OF LAW [insert]: And the matter having duly come on for a dispositional hearing, and the following person(s) having appeared [specify]: before this Court for the dispositional hearing; and [Applicable where guardianship and custody are committed to an authorized agency ]: The Court having determined that t he following individual(s) would be entitled to notice of an adoption pursuant to Domestic Relations Law §111-a [specify name(s)]: And the Court having determined that such person(s) had had not been provided with notice of the proceeding and that such person(s) had had not appeared; [Finding Regarding Consent to Adoption by Child 14 or older]: The above-named child, who was born on [specify date of birth]: has consented to adoption by [specify]: has withheld consent to adoption by [specify]: for the following reasons [specify, including information furnished by the attorney for the child and/or child]: The Court, having made examination and inquiry into the facts and circumstances of the case and into the surroundings, conditions and capacities of the persons involved in this proceeding, finds that the best interests of the child require the disposition hereinafter made; NOW, therefore, it is ORDERED AND ADJUDGED that the following parent(s) of the above-named child are deceased [specify]: ; and it is [Check applicable box(es)]: ORDERED that the guardianship and custody rights of [specify]: are transferred to [specify]: , an authorized agency foster parent(s); and such guardianship and custody of the child are committed to the authorized agency foster parent(s) upon the following terms and conditions [specify]: And it is further ORDERED that [specify]: is authorized and empowered to consent to the adoption of the child subject to the order of a Court of competent jurisdiction to which a petition for adoption is submitted without the consent of or further notice to [specify]: , the [specify relationship to the child]: Applicable where guardianship and custody have been transferred to the Petitioner: AND IT IS FURTHER ORDERED that the Petitioner herein shall forthwith advise the preadoptive foster parents(s) of his/her/their right to file an adoption petition in a court of competent jurisdiction and further advise the pre-adoptive foster parent(s) as to all necessary supporting documents; AND IT IS FURTHER ORDERED that a certified copy of this order be filed for recording at the Office of the County Clerk in accordance with the provisions of Section 384-b of the Social Services Law; American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-5 Page 3 Applicable Where Child is Native-American ORDERED that the following should be notified of this proceeding [specify]: the custodian of the child; tribe/nation; United States Secretary of the Interior ORDERED that in light of the assumption of jurisdiction by the tribe/nation, this proceeding is DISMISSED WITHOUT PREJUDICE. Required Date Certain for Permanency Hearing [Required in all cases in which the child is in the guardianship and custody of the authorized agency or foster parent]: ORDERED that if the child remains in the custody and guardianship of the authorized agency or foster parent, the next permanency hearing shall be held on [specify date certain within 30 days of the earlier of the Court's announcement of its decision or issuance of this Order]: And it is further ORDERED that Petitioner shall transmit notice of the hearing and a permanency report no later than 14 days in advance of the above date certain other date [specify]: to all parties, attorneys, the attorney for the child and any pre-adoptive parent or relative providing care to the child(ren) and, unless dispensed with by the Court, shall transmit notice of the hearing to former foster parent(s) who have had care of the child(ren) in excess of 12 months. AND IT IS FURTHER ORDERED that ENTER _____________________________________ Judge of the Family Court PURSUANT TO SECTION 1113 OF THE FAMILY C