Soc. Serv. Law §§ 383-c, 384 Form SURR-3 (Petition for Approval of ExtraJudicial Surrender Instrument) (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 Child's Name: Date of Birth: CIN # Pursuant to Section G 383-c G 384 of the Social Services Law ........................................................................................ TO THE FAMILY COURT OF THE COUNTY OF Docket No. PETITION FOR APPROVAL OF EXTRA-JUDICIAL SURRENDER INSTRUMENT : The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner, [specify]: having its office and place of business at [specify]: [specify]: , State of New York. , is an authorized agency in the County of 2. a.. The child, [specify]: , is a [check applicable box]: G male G female child under the age of eighteen years, born on [specify date]: at [specify]: , who now resides in the County of [specify]: , State of New York. b. The subject child is is not a Native-American child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). 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]: 3. a. The child is now in the custody of the Petitioner and resides with [specify, unless confidential]: b. [Applicable to surrenders pursuant to Social Services Law §383-c]: The child entered foster care on [specify]: as a result of [specify proceeding, docket number court and status]: The most recent permanency hearing was held in [check applicable box]: G this Court G another Court [specify]: on [specify date]: 4. The guardianship of the person and custody of the child have been committed to the Petitioner by a written instrument of surrender, signed on [specify date]: by [check applicable box(es)]: a. G mother [specify]: American LegalNet, Inc. www.FormsWorkflow.com Form SURR-3 Page 2 b. G father [specify]: [Applicable if surrender executed by father]: Paternity was established by [check applicable box; if not established, so state]: G Marriage between the above-named parents. G An order of filiation entered on [specify date and court]: G An acknowledgment of paternity signed on [specify date]: c. G legal guardian [specify]: 5. [Applicable if surrender was executed by one parent or by legal guardian]: The child's parent or parent(s), other than the parent(s) who executed the surrender, is or are as follows [check applicable box(es)]: a. G The child's mother [specify]: G retains parental rights to the child. G is or was the subject of the following child abuse, child neglect, foster care placement or review and/or child custody proceeding(s) [specify type of proceeding, court, docket number, date filed, final disposition or order, if any, and current status of proceeding, if available]: G surrendered the child on [specify date]: G is the subject of a pending surrender proceeding [specify date filed, court and status]: G had her rights to the child terminated on [specify date]: G is the subject of a pending termination of parental rights proceeding [specify date filed, court and status]: G is deceased G is unknown. b. 9 The child's father is [specify]: 1). Paternity was established by [check applicable box; if not established, so state]: G Marriage between the above-named parents. G An order of filiation entered on [specify date and court]: G An acknowledgment of paternity signed on [specify date]: 2). The child's father [specify]: G retains parental rights to the child. G is or was the subject of the following child abuse, child neglect, foster care placement or review and/or child custody proceeding(s) [specify type of proceeding, court, docket number, date filed, final disposition or order, if any, and current status of proceeding, if available]: G surrendered the child on [specify date]: G is the subject of a pending surrender proceeding [specify date filed, court and status]: G had his rights to the child terminated on [specify date]: G is the subject of a pending termination of parental rights proceeding [specify date filed, court and status]: American LegalNet, Inc. www.FormsWorkflow.com Form SURR-3 G is deceased. G is unknown. Page 3 6. In addition to the above-named child's parent(s) or guardian(s), the following individuals must be notified of this proceeding, pursuant to Social Services Law §384-c [specify]: Name Address [unless confidential] Relationship There are no persons other than those set forth above entitled to notice pursuant to Section 384-c of the Social Services Law. 7. a. [Applicable to surrender of child in foster care]: The instrument of surrender was executed and acknowledged before [specify at least two witness(es)]: whose affidavit(s) (is)(are) attached to, and made a part of, this petition.1 b. [Applicable to surrender of child not in foster care]: The instrument of surrender was executed and acknowledged before [specify at least one witness]: 8. [Applicable to surrender of child in foster care; check applicable box(es)]: a. Supportive counseling for the person executing the surrender was 9 offered 9 arranged by [specify]: , an employee of the following authorized agency [specify]: , whose affidavit is attached to, and made a part of, this petition.2 b. Supportive counseling for the person executing the surrender was: G provided by [specify]: , whose affidavit is attached to, and made part of, this petition. The counseling was provided on [specify date]: as follows [specify]: G not provided because: G the offer of counseling was rejected by the person executing the surrender G other reason [specify]: 9. a. The surrender is subject to the following condition(s)[specify]: , b. [Applicable where surrender is subject to condition of adoption by specific individual]: The surrender is conditional upon adoption by [specify]: , who, in accordance with regulations of the NYS Office of Children and Family Services, has been [check applicable box(es)]: G investigated and approved as a prospective adoptive parent G certified or approved as a foster parent c. [Applicable where post-adoption contact agreement has been signed]: The annexed postadoption contact agreement is in the child's best interests for the fol