D.R.L.§ 115-c S.C.P.A.§ 1725. Form 21-B (Order of Temporary Guardianship) 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 , . PRESENT: Hon. Judge _________________________________ In the Matter of the Temporary Guardianship of A Child Whose First Name is (Docket)(Fil Docket No. ORDER (Temporary Guardianship of the Person) ________________________________ Upon reading and filing the petition herein duly verified on applying for Q temporary guardianship of , a child placed for adoption, Q an order approving the adoption of , an adoptive child, and it appearing that the child will be residing with the Petitioner(s) and that Petitioner(s) intend to file for adoption of the child within 45 days of the execution of the consent to the adoption of the child, and the Court having inquired of the statewide central register of child abuse and maltreatment and having been informed that: Q the child Q is Q is not the subject of or another person named in an indicated report Q the Petitioner(s) Q is/are Q is/are not the subject of or another person named in an indicated report filed with such register as such terms are defined in section 412 of the Social Services Law, and the Court having given due consideration to any information contained therein, And it appearing further that it Q is grant the petition Q is not in the best interests of the child to NOW therefore, it is hereby [check applicable box(es)]: QORDERED that said application for temporary guardianship is GRANTED; and it is further QORDERED that the person of be appointed temporary guardians of ; and it is further . QORDERED that this order shall expire on or the date a final order of adoption is entered, whichever is sooner. American LegalNet, Inc. www.FormsWorkFlow.com Form 21-b Page 2 QORDERED, that the application for temporary guardianship is DENIED; and it is further QORDERED that the proceeding herein be continued for further investigation; (and it is further) QORDERED that upon notice to , the Petitioner(s) shall appear on the day of , , at to show cause why the child should not be removed from their home; PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. ENTER ____________________________________ Judg Judge of the Family Court / Surrogate Dated: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________