F.C.A 247247 661; 1089 - a; S.C.P.A.247247 1701 - 1707 Form 6 - 1 - c [ NOTE : In kinship guardianship cases , this form ( Petition for A ppointment as should be used only by Petitioners, who h ave K inship Guardian [Subsid ized fully executed agreements with the local social services district Kinship Guardian Program] under the NYS Subsidized Kinship Guardian Program] and/or Permanent Guardian) 3/2018 ... ................................. .............................. Proceedings for the Appointment of a Kinship guardian (Subsidized Kinship Guardian Program) Docket No. Permanent Guardian Family File No. of PETITION FOR APPOINTMENT AS Kinship Guardian [Subsidized A Person Under the Age of 21 Kinship Guardian Program] Permanent Guardian ................................................................. TO THE FAMILY COURT: The Petitioner(s) respectfully allege(s) to this Court that: 1. a. I, [specify name]: am submitting this petition i n order to be appointed [check one or both boxes]: Kinship Guardian in conjunction with the NYS Subsidized Kinship Guardian Program 1 Permanent Guardian 2 of the person under the age of 21 who is the subject of this petition. I live at [specify name and complete address of residence]: 3 1 best interests, that the guardian and the local social services district have a fully executed agreement for payments in accordance with Title 10 of Article 6 of the Social Servi ces Law and that the guardian has cared for the child as a fully certified or approved foster parent for at least six consecutive months prior to the application for the guardianship subsidy. The prospective guardian may be: related to the child by blood , marriage or adoption; or related to the - sibling by blood marriage or adoption, where the prospective guardian is the prospective or actual guardian of such sibling; or has a positive relationship with the child, such as a step - parent, godpar ent, neighbor or family friend. Note that by executing the agreement with the prospective guardian, the social services district has indicated that it has determined the prospective guardian to be eligible for the Subsidized Kinship Guardian subsidy, cont ingent upon the that if the related proceeding was a child protective proceeding, the fact - finding and permanency hearings must have bee n completed, or, if the related proceeding was a voluntary foster care, PINS, juvenile delinquency or freed - child permanency proceeding, that a permanency hearing has been completed in such proceeding. Persons over the age of 18 linemust consent to the ki payments may last until the person reaches the age of 21. 2 Act 2471702(2), if the Court finds that it is in the best interests of a person under the age of 21, who has been committed to an authorized agency through termination of parental rights or surrender or whose birth parents or othe r persons entitled to notice of, or to consent to, adoption are deceased. Persons over the age of 18 must consent to such an appointment, which may last until the person reaches the age of 21. A person may be appointed as both a permanent and a subsidized kinship guardian. 3 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act 247154 - b. American LegalNet, Inc. www.FormsWorkFlow.com Form 6 - 1 - c Page # b. [Applicable if more than one Petitioner; if not, skip to 266 2]: I, [specify name]: am submitting this petition in order to be appointed [check one or both boxes]: Kinship Guardian in conjunction with the NYS Subsidized Kinship Guardian Program 4 Permanent Guardian 5 of the person under the age of 21 who is the subject of this petition. I live at [specify name and complete address of residence]: 6 2. The name, date of birth and residence of the person under the age of 21 who is the subject of this proceeding are as follows: Name: Date of Birth: Complete address: 7 3. The subject of this proceeding is is not a Native American child under the age of 18 who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. 2472471901 - 1963). If so, the following have been notified [check applicable box(es)]: parent/custodian [specify name and give notification date]: tribe/nation [specify name and give notification date]: United States Secretary of the Interior [give notification date]: 4. The name and relationship of person with whom the child who is the subject of this proceeding resides are as follows: Person with whom subject child resides [specify name]: Relationship to subject child: Address [include street, city, village or town, county and state]: 8 5. (Upon information and belief) The religion of the child who is the subject of this proceeding is [specify]: 6. (Upon information and b elief) The names, relationship and post office addresses of the birth parents of the subject child of the proceeding, the name and address of the person with whom the 4 See note 1. 5 See note 2. 6 See note 3. 7 See note 3. 8 See note 3. American LegalNet, Inc. www.FormsWorkFlow.com Form 6 - 1 - c Page 3 subject child resides, if other than the parent(s), on whom process should issue; and su ch other persons concerning whom the court is required to have information, are as follows: [If either birth parent is dead or has surrendered or has had parental rights terminated (TPR), so allege; if both parents are dead, indicate nearest adult next of kin]: Relationship Name Complete Address Deceased? TPR? Surrender? Birth mother: Birth father: Person with whom the subject child resides, if other than parents: Adult next of kin, if birth parents are dead : Other [specify]: 9 7. (Upon information and belief) [check applicable box(es)]: a. Appointing me/us as the kinship guardian (in conjunction with the Subsidized Kinship Guard ian Program) permanent guardian best interests and would preserve his/her legal rights because [specify facts regarding the suitability, ability and commitment of the proposed guardian(s) to as sume full legal responsibility and raise him/her to adulthood]: b. (i) In related proceedings regarding the above - named child [check applicable box]: [Applicable to related child protective proceedings]: Fact - finding and permanen cy hearing have been completed pursuant to Family Court Act 2472471051 and 1089; [Applicable to voluntary foster care, juvenile delinquency, PINS a nd freed - child proceedings]: A permanency hearing has been completed pursuant to Family Court Act 247247355.5, 756 - a or 1089; (ii) [For kinship guardianship proceedings only]: [ Petitioner #1 ]: I am related to the child through blood, marriage, or adoption as follows [specify]: s half - sibling through blood, marriage, or adoption and am the half - I have a positive relationship with the child as follows [specify, for example, 9 Include Mental Hygiene Legal Services, if the subject of the proceeding is intellectually or developmentally disabled and has been admitted to a facility, and any person entitled to notice of or consent to the adoption of the subject of the proceeding. American LegalNet, Inc. www.FormsWorkFlow.com Form 6 - 1 - c Page 4 whether step - parent, godparent, neigh bor, family friend or other connection]: [ Petitioner #2, if any ]: I am related to the child through blood, marriage, or adoption as follows [specify]: - sibling through blood, marriage, or adoption and am the half - I have a positive relationship with the child as follows [specify, for example, whether step - parent, godparent, neighbor, family friend or other connection]: (iii) [For kinship guardianship proceedings only]: I/we have been caring for the child as a fully certified or approved foster parent(s) since [specify date]: , which is at least six consecutive months prior to [speci fy date] , the date of my/our application to the local social services district for kinship guardianship assistance payments.. (iv) [Check applicable box]: Care and custody guardianship and custody have been awarded to [specify local social services district, including county if outside New York City, or authorized child care agency]: The local social services district and I/we have a fully