F.C.A. §1034(2) Form10-29a (Child Protective-Application for Order for Access to Child(ren) and/or Home-Before Petition Filed) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of Docket No. A Child(ren) Under the Age of Eighteen Alleged to be Abused or Neglected by APPLICATION FOR ORDER FOR ACCESS TO CHILD(REN) AND/OR HOMEBefore Petition Filed Respondent(s) TO THE FAMILY COURT: I, [specify name]: , having been duly sworn, state the following: 1. I am [ specify job title, agency and county]: 2. (Upon information and belief,) the child(ren) who are the subject(s) of this application is/are: Name Sex Date of Birth Custodial Parent/Guardian Child’s Address [Select Paragraph 3(a) OR 3(b) and check applicable boxes]: 3. “ a. Based upon the report of suspected child abuse or maltreatment, dated [specify]: and my subsequent investigation, I have reasonable cause to suspect that the life or health of the following child(ren) [specify]: may be in danger. However, “ I have been unable to locate the above-named child or other children in the household; or “ On [specify date]: , I visited the child(ren)’s home at the address set forth in ¶1, but was denied access to the child (ren) sufficient to determine his/her/their safety; “ b. Based upon the report of suspected child abuse or maltreatment, dated [specify]: and my subsequent investigation, I have probable cause to believe that an abused or neglected child or children may be located at the address set forth in ¶1, but on [specify date]: I visited the child(ren)’s home at that address, but was denied access to the home to investigate; 4. On [specify date]: I advised [specify parent or other person legally responsible]: that, if access to the child and/or home, as applicable above, was denied, I may seek an immediate court order for such access; American LegalNet, Inc. www.FormsWorkflow.com Form 10-29a Page 2 5. [REQUIRED if application is made when the Family Court is not in session or if it is later than the Family Court’s deadline for new applications]: I would like to contact the Family Court judge by telephone. I can be reached at [specify telephone number]: I am able to receive the Court’s order at [specify e-mail and/or fax number]: 6. No previous application has been made to any court or judge for the relief requested herein (except [specify]: ). WHEREFORE, for the reasons stated above, I am requesting that the Family Court issue an order [check applicable box(es)]: [Applicable where paragraph 3(a) was selected]: “ requiring the parent or other person legally responsible to bring the following child or children [specify names]: “ immediately at any hour “ between the hours of 6AM and 9 PM for observation and interviews outside the presence of the parent or other person legally responsible : “ to the following Child Advocacy Center [specify name and address]: “ to the following person for an interview and observation [specify name and address of interview/observation location]: “ to the Petitioner/Applicant for an interview and observation as follows [specify, including address of interview/observation]: OR [Applicable where paragraph 3(b) was selected]: “ requiring the parent or other person legally responsible to permit me to enter the home “ immediately at any hour “ between the hours of 6AM and 9 PM , in order to: “ determine whether an abused or neglected child or children is/are present; “ conduct a home study to evaluate the home environment of the child or children; Dated: Signature of Applicant Print Name Title, Agency and County Sworn to before me this day of , (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkflow.com