F.C.A §§1017, 1022 Form 10-1 (Child Protective--Order Directing Temporary Removal of Child Before Filing of Petition) 6/2016 At a term of the Family Court of the State of New York, held in and for the County of , at New York on , . P R E S E N T: Hon. Judge -----------------------------------------------In the Matter of FAMILY FILE #: CIN # A Child(ren) under the Age of Eighteen Years Alleged to be "Abused "Neglected by 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. Docket No. ORDER DIRECTING TEMPORARY REMOVAL OF CHILD (Before Filing of Petition) THE CHILD ABUSE OR NEGLECT PETITION MUST BE FILED BY [specify date/time]: THE REMOVAL HEARING [F.C.A.§1027] SHALL BE HELD ON [specify date/time]: THE PERMANENCY HEARING SHALL BE HELD ON [ SPECIFY DATE/TIME]:1 An application having been made to this Court by [check applicable box]: " a duly authorized child protective agency [specify]: ; Specify a date certain not more than eight months from the date of removal. If the child has a sibling or half-sibling removed from the home, whose permanency hearing is scheduled before this Court, the date certain shall be the same as the date certain for the sibling's or half-sibling's permanency hearing, unless the sibling or half-sibling was removed on a juvenile delinquency or PINS petition or unless he or she has been freed for adoption. If the child is finally discharged from care on the scheduled date, the permanency hearing shall be cancelled. 1 American LegalNet, Inc. www.FormsWorkFlow.com Form 10-1 Page 2 or " a person authorized by the Court [specify]: for an order directing the temporary removal of the above-named child(ren) from their residence pursuant to Section 1022 of the Family Court Act ; And the Respondent(s) [check applicable box(es) ]: " having been present at the hearing of this application; and having " been represented " not been represented " waived representation by counsel; " having not been present at the hearing of this application, but [check box]: " having been given notice of this application by [specify]: " having not been given notice of this application; [Check box if applicable]: " And the following Non-respondent parent was present and " was " was not represented by counsel; [Required in cases involving Native-American children; check if applicable ]: " And the following having been duly notified [check applicable box(es)]: " parent/custodian " tribe/nation " United States Secretary of the Interior; And the tribe/nation having: " appeared and participated as a party; " appeared and declined to assume jurisdiction; " appeared and requested transfer of jurisdiction; " not appeared; The Court finds and determines the following [Note: judicial findings must be made pursuant to I and II and, below, if temporary removal is GRANTED]: I. Criteria for Temporary Removal of Child(ren) [All four criteria, A, B, C and D, must be met]: A. The " parent " person legally responsible for the child(ren) [check applicable boxes]: " is absent and cannot be located after reasonable effort to do so; or " was asked and refused to consent to temporary removal of the child(ren) and " was " was not informed of an intent to apply for an order of removal; or " consented to the temporary removal of the child(ren) ; and B. The child(ren) appear(s) to so suffer from abuse or neglect by the " parent(s) " person(s) legally responsible for the child(ren)'s care ; and C. Immediate removal of the child(ren) is necessary to avoid imminent danger to the child(ren)'s life or health because [specify facts and reasons, including specific documents or evidence supporting findings]: ; and D. There is not enough time to file a petition and hold a preliminary hearing under Section 1027 of the Family Court Act. II. Required "Best Interests" and "Reasonable Efforts" Findings [check applicable boxes and provide case-specific reasons in both A and B, below]: A. Continuation in the child(ren)'s home " would " would not be contrary to the best interests of the child(ren) because [specify facts and reasons]: American LegalNet, Inc. www.FormsWorkFlow.com Form 10-1 Page 3 This determination is based upon the following information [check applicable box(es)]: " Report of Suspected Child Abuse or Neglect " Case Record, dated [specify]: " Service Plan, dated [specify]: " The report of [specify]: , dated [specify]: " Testimony of [specify]: " Other [specify]: B. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the child(ren) from the home [check applicable box and state reasons as indicated]: " were made as follows [specify]: " were not made but the lack of efforts was appropriate [check all applicable boxes]: " because of a prior judicial finding that the Petitioner was not required to make reasonable efforts to reunify the child(ren) with the Respondent(s) [specify date of finding]: " because [specify other reason(s)]: " were not made. This determination is based upon the following information [check applicable box(es)]: " Report of Suspected Child Abuse or Neglect " Case Record, dated [specify]: " Service Plan, dated [specify]: " The report of [specify]: , dated [specify]: " Testimony of [specify]: " Other [specify]: III. Findings Regarding Alternatives to Removal to Foster Care: A. Based upon the investigation conducted by the Commissioner of Social Services, including a review of records in accordance with section 1017 of the Family Court Act, [Check applicable box(es]: " The following person [specify]: is a " non-respondent parent "legal custodian2 or guardian " relative " suitable person with whom the child(ren) may appropriately reside. [Applicable to non-respondent parent]: Such non-respondent parent: " wishes the child(ren) to be released to him/her during the pendency of this proceeding. " wishes to be granted a temporary order of custody, pursuant to a proceeding under Article 6 of the Family Court Act and has filed a petition, Docket # , which [check applicable box]: 2 "Legal custodian" refers to an individual with an order of cu