F.C.A. §1022 Form10-1c (Child Protective-Application for Pre-petition Temporary Removal of Child(ren) From Home) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of Docket No. CIN # A Child(ren) Under the Age of Eighteen Alleged to be “Abused “Neglected by APPLICATION FOR PRE-PETITION TEMPORARY REMOVAL OF CHILD(REN) FROM HOME Respondent(s) NOTICE: IF YOUR CHILD STAYS IN FOSTER CARE FOR 15 OF THE MOST RECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAW TO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END OF THE 15-MONTH PERIOD. IF SEVERE OR REPEATED ABUSE IS PROVEN BY CLEAR AND CONVINCING EVIDENCE, THIS FINDING MAY CONSTITUTE THE BASIS TO TERMINATE YOUR PARENTAL RIGHTS. IF THE PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. TO THE FAMILY COURT: The undersigned, , is [check applicable box]: G the [state title, agency and county]: a duly authorized child protective agency, with offices at [specify]: “ a person authorized by the Court [specify]: and respectfully alleges that: 1. a. (Upon information and belief,) the child(ren) who are the subject(s) of this application is/are: The child(ren) who (is) (are) the subject(s) of this proceeding (is)(are): Name Sex Date of Birth Custodial Parent/Guardian Child’s Address b. (Upon information and belief) The father and mother of the child(ren) and their American LegalNet, Inc. www.FormsWorkFlow.com Form 10-1c Page 2 respective residence addresses are: Name of Child(ren) Name of Parent Parent’s Address 2.. (Upon information and belief,), the child(ren) require immediate protection and should be temporarily removed from home prior to the filing of a child protective petition for the following reasons: a. The parent or other person legally responsible for the child(ren)’s care was: G absent; G present but refused, when asked, to consent to the child(ren)’s temporary removal and was informed of this application; b. The child(ren) appear(s) to suffer from abuse or neglect such that immediate removal is necessary to avoid imminent danger to the child’s life or health, because [specify]: c. There is not enough time to file a petition and hold a preliminary hearing pursuant to Family Court Act §1027. 3. 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]: 4. a. Continued placement in the parent’s home [check applicable box]: Q would Q would not be contrary to the child(ren)’s best interests, based upon the following facts and for the following specific reasons [specify]: This assertion is based upon the following specific documents and evidence: “ Report of suspected abuse or maltreatment, dated [specify]: “ Case record, dated [specify]: “ Service Plan, dated [specify]: “ The report of [specify]: , dated [specify]: “ Other [specify]: ; AND b. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the child(ren) from the home: “ were made as follows [specify reasonable efforts, including specific documents or evidence supporting findings]: “ were not made but the lack of efforts was appropriate [check all applicable boxes]: “ because of a prior judicial finding that the authorized agency was not required to make reasonable efforts to reunify the child(ren) and their parent(s)[specify date of finding]: “ because [specify other reasons]: American LegalNet, Inc. www.FormsWorkFlow.com Form 10-1c Page 3 “ were not made. This assertion is based upon the following specific documents and evidence: “ Report of suspected abuse or maltreatment, dated [specify]: “ Case record, dated [specify]: “ Service Plan, dated [specify]: “ The report of [specify]: , dated [specify]: “ Other [specify]: 5. No previous application has been made to any court or judge for the relief requested herein (except [specify]: ). WHEREFORE, the undersigned requests that an order be made pursuant to Family Court Act §1022 temporarily removing the child(ren) from the home of [specify parent(s) or person(s) legally responsible]: and placing the child(ren) temporarily in the care and custody of the Department of Social Services of [specify county]: County, pending the filing of a child protective petition and the convening of a hearing pursuant to Family Court Act §1027, and directing such other and further relief as to the Court may seem just and proper. Dated: (Agency) By: (Title) VERIFICATION STATE OF NEW YORK COUNTY OF ) ) ss.: ) , being duly sworn, deposes and says: That (s) he is the [specify title and agency]: G an authorized child protective agency G person authorized by the Family Court , and is acquainted with the facts and circumstances therein; that (s) he has read the foregoing and knows the contents thereof; that the same is true to (his)(her) own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters (s) he believes it to be true. Name Sworn to before me this day of , . Title (Deputy)(Clerk of Court) (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com