F.C.A. §1028-a Form 10-17a (Affidavit in Support of Motion for Order Approving Relative as Foster Parent) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ...................................................................................... In the Matter of Docket No. CIN # AFFIDAVIT IN SUPPORT OF A Child Under the Age of 18 MOTION FOR AN ORDER Alleged to be GAbused GNeglected by APPROVING RELATIVE AS FOSTER PARENT ..............................................Respondent(s)........................................ STATE OF NEW YORK ) ) SS.: COUNTY OF NEW YORK ) I, [specify name]: penalties of perjury: , swear the following to be true under the 1. I am the [specify kinship relationship to the child(ren)]:1 and am willing and qualified to provide foster care for the child(ren). 2. On [specify date]: , I received a notice that [specify child(ren)]: , the above-named child(ren), was/were removed from his/her/their home on [specify date]: and was/were G remanded Gplaced in foster care on [specify date]: . 3. On [specify date]: , I made a request to [specify official and agency]: to approve me as a foster parent and place the child(ren) in my care. However, the Department of Social Services has refused my request to place the child(ren) with me and has given me the following reason(s) for this refusal [specify]: 4. G I have never refused on any prior occasion to provide care for the child(ren). G On [specify date]: , I was asked by [specify]: to provide care for the child(ren), but I was unable to do so at that time because of a lack of [check box(es)]: G sufficient financial resources G appropriate housing G appropriate educational arrangements G other reason [specify]: 1 This application may be made by relatives up to the third degree of consanguinity to either parent, that is, adult siblings of the child; grandparents, great-grandparents and great-great-grandparents of the child(ren); aunts, uncles, great-aunts, great-uncles of the child(ren) and their spouses. See 18 N.Y.C.R.R.§443.1(i). American LegalNet, Inc. www.FormsWorkflow.com Form 10-17a Page 2 5. I believe I am qualified to provide foster care for the child(ren) and that it would be in the best interests of the child(ren) to be placed in my care for the following reason(s)[explain fully]: 6. (a). (Upon information and belief), neither I nor anyone over the age of 18 living in my home have been the subject of an indicated report of child abuse or maltreatment, as such terms are defined in section 412 of the Social Services Law, or has been the respondent in a child protective proceeding that resulted in an order finding that any child is an abused or neglected child, except [specify]: (b)[Check applicable box(es)]: Upon information and belief, G Neither I nor any other adult over the age of 18 residing in my home have a criminal conviction. G I have been convicted of the following offenses [specify, including dates of convictions and sentences]: [Applicable if my criminal conviction is for a felony listed in Social Services Law §378-a]: 2 G Denial of my application to be approved as a foster parent and to provide foster care to the child(ren) will create an unreasonable risk of harm to their physical or mental health and granting my application will not place the child(ren)’s safety in jeopardy and will be in the best interests of the child(ren) for the following reasons [specify]: G The following adult over the age of 18 living in my home [specify]: has the following criminal conviction(s) [specify, including dates of convictions and sentences]: WHEREFORE, for the reasons stated above, I respectfully request this Court to issue an order granting my motion for an Order , pursuant to Section 1028-a of the Family Court Act, placing the above-named child(ren) in foster care to reside with me, directing the commissioner of social services to commence an investigation of my home within 24 hours and thereafter expedite my approval or certification, if deemed qualified, as a foster parent. Affiant Sworn to before me this day of , (Deputy) Clerk of the Court Notary Public 2 These crimes include: (A) a felony conviction at any time involving: (i) child abuse or neglect; (ii) spousal abuse; (iii) a crime against a child, including child pornography; or (iv) a crime involving violence, including rape, sexual assault, or homicide, other than a crime involving physical assault or battery; or (B) a felony conviction within the past five years for physical assault, battery, or a drug-related offense. See Social Services Law §378-a. American LegalNet, Inc. www.FormsWorkflow.com