F.C.A. ''1017, 1033-b, 1040, 1044,Form 10-10 1046, 1051, 1052, 1053,(Child ProtectiveBOrder of Fact-finding, 1054, 1055, 1057, 1059, 1089Disposition and Permanency Hearing) 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 EighteenYears of Age Alleged to beGAbused G Neglected by Respondent(s) Docket No. ORDER OF FACT-FINDING AND DISPOSITION (AND PERMANENCY HEARING) GAbuse G NeglectGSevere Abuse G Repeated AbuseNOTICE: WILLFUL FAILURE TO OBEY THE TERMS AND CONDITIONS OF THIS ORDER MAY RESULT IN COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS. IF YOUR CHILD(REN) STAY 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(REN) AND YOUR CHILD(REN) MAY BE ADOPTED WITHOUT YOUR CONSENT. THE NEXT COURT DATE IS [specify date/time]: THE NEXT PERMANENCY HEARING SHALL BE HELD ON [SPECIFY DATE/TIME]: 1 1 If a combined dispositional/permanency hearing was held and the child(ren) have been placed, specify a date certain not more than six months from the completion of the hearing. If solely a dispositional hearing was held, specify a date, in most cases the previously-scheduled date, not more than eight months from date of removal of child(ren) from home. No date needs to be set if :(i) the petition is dismissed; or (ii) the child(ren) have not been removed from home; or (iii) have been finally discharged from care; or (iv) custody or guardianship was ordered pursuant to Family Court Act Article 6. If the child(ren) have been placed and the child(ren) have a sibling or halfsibling 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 s he or she has been freed for adoption. American LegalNet, Inc. www.FormsWorkFlow.com Form 10-10 Page 2 The petition of [specify]: under Article 10 of the Family Court Act, sworn to on [specify date]: , having been filed in this Court alleging that the above-named Respondent(s) [check applicable box(es)]: G neglected G abused G severely abused G repeatedly abused G the above-named child; and Notice having been duly given to the Respondent(s) pursuant to section 1036 or 1037 of the Family Court Act; and [Include separate paragraphs for each Respondent, as necessary]: Respondent [specify]: having: G appeared G with counsel G without counsel G waived counsel G not appeared; G not appeared after service G not appeared but service could G not be made after every reasonable effort had been made to effect service not app eared but counsel appeared; Respondent [specify]: having: G appeared G with counsel G without counsel G waived counsel G not appeared; G not appeared after service G not appeared but service could not be made after every reasonable effort had been made to effect service not appeared but counsel appeared; And Respondent [specify]: having: G voluntarily, intelligently and knowingly admitted in open court that (s)he committed the following act(s) [specify]: G denied the allegations of the petition and the matter having duly come on for a fact- finding hearing before this Court; G failed to appear and the matter having duly come on for a fact- finding hearing by inquest before this Court; G voluntarily, intelligently and knowingly consented to the entry of an order of fact- finding without admission pursuant to Family Court Act '1051(a), and the Petitioner, Child(ren)=s attorney and all other parties having consented to the entry of such order of fact-finding as well; And Respondent [specify]: having: G voluntarily, intelligently and knowingly admitted in open court that (s)he committed the following act(s) [specify]: G denied the allegations of the petition and the matter having duly come on for a fact-finding hearing before this Court; G failed to appear and the matter having duly come on for a fact- finding hearing by inquest before this Court; G voluntarily, intelligently and knowingly consented to the entry of an order of fact finding without admission pursuant to Family Court Act '1051(a) , and the Petitioner, Child(ren)=s attorney and all other parties having consented to the entry of such order of fact-finding as well; And where the parent(s) of the above-named child(ren) are not the Respondent(s), the parent(s) were: present at the hearing and participated as interested party-intervenor(s); G served with a notice and copy of the petition but did not appear; American LegalNet, Inc. www.FormsWorkFlow.com Form 10-10 Page 3 G were not served with a notice or copy of the petit ion and did not appear; although G every reasonable effort had been made to effect service; G And the child(ren) having been represented by (an) attorney(s); G And the following other interested party-intervenors were present and participated in the hearing [specify name(s) and relationship(s) to child(ren)]: [Required in cases involving Native-American children; check if applicable]: G And the following having been duly notified [check applicable box(es)]: G parent/custodian G tribe/nation G United States Secretary of the Interior; And the tribe/nation having: appeared and participated as a party; G appeared and declined to assume jurisdiction; G appeared and requested transfer of jurisdiction; G not appeared; And the Court, after [check box] G hearing the proof and testimony offered in relation to the case; OR G accepting the consent of the Respondent, Petitioner and Child(ren)=s attorney to the entry of an order of finding without admission, pursuant to Family Court Act '1051(a); OR G accepting the admission by Respondent [specify]: and having found [check applicable box(es) and specify act(s) of child abuse and/or neglect found, if any, with respect to each child]: G by a preponderance of the evidence that Respondent [specify]: committed the following acts constituting child neglect child [specify act(s), including name(s) of the child(ren), the Penal Law section, if applicable, and grounds for determination]: G by a preponderance of the evidence that Respondent [specify]: committed the following acts constituting G child neglect G child abuse [specify act(s), including name(s) of the child(ren), the Penal Law section, if applicable , and grounds for determination]: [Applicable only where severe or repeated abuse was alleged and Respondent was so advised]: G by clear and convincing evidence that Respondent [specify]: severely repeatedly abused the child(ren) by committing the following acts(s) [specify act(s), including the name(s) of the child(ren), the Penal Law section, if applicable; and grounds for determination]: G by clear and convincing evidence that Respondent [specify]: severely repeatedly abused the child(ren) by committing the following acts(s) [specify act(s), American LegalNet, Inc. www.FormsWorkFlow.com Form 10-10 Page 4 including the name(s) of the child(ren), the Penal Law section, if applicable; and grounds for determination]: And the matter having thereafter duly come on for a [check applicable boxes]: G DISPOSITIONAL HEARING; G PERMANENCY HEARING before the Court, [Applicable only where hearing was heard jointly with hearing of Family Court Act Article 6 custody or guardianship petition, pursuant to Family Court Act '1055-b; Check Box if applicable]: G And the hearing having been heard jointly with the G custody G guardianship petition, Docket # [specify]: [Applicable only to combined dispositional/permanency hearing; check box(es) if applicable] : G And the following person(s) were given notice of the permanency hearing and appeared as indicated below [specify; check applicable boxes]: C