Soc. Serv. Law §§ 383-c(4) Form SURR-4 (Affidavit of Authorized Agency Employee Witness to Execution of Extra- Judicial Surrender of Child in Foster Care) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Application for Approval of a Surrender Instrument Concerning CIN # Pursuant to Section 383-c of the Social Services Law ........................................................................................ STATE OF NEW YORK )ss.: COUNTY OF I , [specify name of witness]: following: ) ) Docket No. AFFIDAVIT OF AUTHORIZED AGENCY EMPLOYEE WITNESS TO EXECUTION OF EXTRAJUDICIAL SURRENDER OF CHILD IN FOSTER CARE , having been duly sworn, deposes and states the 1. I am an employee of the following authorized agency [specify]: and have been trained to receive surrenders in accordance with regulations of the New York State Office of Children and Family Services. 2. On [specify date]: , I witnessed the execution and acknowledgment of the surrender of the above-named child by [specify]: at the following location [specify]: 3. The person executing the surrender instrument was provided with a copy of the surrender and the surrender was read in full in his or her principal language of [specify]: . The person executing the surrender instrument was given an opportunity to ask questions and obtain answers regarding the nature and consequences of the surrender, including the consequences of, and procedures to be followed in, cases of a substantial failure of a material condition, if any, contained in the surrender instrument. The person executing the surrender instrument was informed of the obligation to provide the authorized agency with a designated mailing address, as well as any subsequent changes in such address, at which the person executing the surrender may receive notices regarding any substantial failure of a material condition, unless this notification is expressly waived by a statement written by the person executing the surrender instrument and appended to or included in the surrender instrument. 4. [Applicable where employee-witness was also the employee responsible for arranging supportive American LegalNet, Inc. www.FormsWorkflow.com Form SURR-4 Page 2 counseling]: a. I am responsible for arranging supportive counseling for parents or guardians who execute extrajudicial surrenders of children in foster care. b. On [specify date]: person executing surrender]: as follows [specify]: c. On [specify date]: 9 accepted 9 did not accept , I arranged for supportive counseling for [specify to be provided by [specify]: , [specify person executing surrender]: the offer of supportive counseling. d. [Check applicable box or delete inapplicable provision]: Upon information and belief, 9 Supportive counseling was provided to the person executing the surrender as follows [specify date, provider and nature of supportive counseling]: 9 Supportive counseling was not provided to the person executing the surrender. _________________________________________________ Signature of Witness to Execution of Extra-judicial Surrender Sworn to before me this day of , ________________________________ Notary Public (Deputy) Clerk of Court American LegalNet, Inc. www.FormsWorkflow.com