F.C.A §§ 1017, 1028 Form 10-5 (Child Protective-Order on Application for Return of Child Temporarily Removed from Home) 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: Docket No. ORDER ON APPLICATION FOR RETURN OF CHILD TEMPORARILY REMOVED FROM HOME 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. THE NEXT COURT DATE IS [specify date/time]: THE PERMANENCY HEARING SHALL BE HELD ON [specify date/time]:1 An application having been made pursuant to Family Court Act §1028 for an order returning the child(ren) to the place of residence of such child(ren) by [specify]: , who (is)(are) the [specify]: " parent(s); " person(s) legally responsible for the 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. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 10-5 Page 2 child(ren); " attorney for the subject child(ren); And the child (ren) having been removed prior to this hearing pursuant to Family Court Act [check applicable box(es)]: " §1021 " §1022 " §1024 " §1027; And a hearing having been held by this Court pursuant to Family Court Act § 1028; and the following person(s) having appeared to determine whether the child(ren) should be returned pending a final order of disposition [specify; check applicable boxes]: " Respondent [specify]: " with counsel " without counsel " waived representation by counsel " Respondent [specify]: " with counsel " without counsel " waived representation by counsel " Non-respondent parent [specify]: " with counsel " without counsel. " Attorney for the child(ren) " Petitioner " Other [specify]: [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 that [Note: judicial findings must be made under I, and, if application for return of child temporarily removed is DENIED, also under II and III ]: I. Criteria for Return or Continued Temporary Removal of Child(ren) [check applicable box]: " The child(ren) should be returned home because no imminent risk to the child(ren)'s life or health has been demonstrated. OR " Continued temporary removal of the child(ren) is necessary to avoid imminent risk to the child(ren)'s life or health. II. Required "Best Interests" and "Reasonable Efforts" Findings [check applicable boxes and provide case-specific reasons in both A and B, below]: A. Continuation of the child(ren) in, or return of the child(ren) to, the child(ren)'s home " would " would not be contrary to the best interests of the child(ren) because [specify facts and reasons]: This determination is based upon the following information [check applicable box(es)]: G Petition G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: , dated [specify]: American LegalNet, Inc. www.FormsWorkFlow.com Form 10-5 Page 3 G Testimony of [specify]: G Other [specify]: B. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the child(ren) from the home, and, if the child(ren) were removed prior to the date of this hearing, to return them home safely [check applicable box and state reasons as indicated]: G were made as follows [specify]: G were not made but the lack of efforts was appropriate [check all applicable boxes]: G because of a prior judicial finding pursuant to F.C.A. §1039-b that the Petitioner was not required to make reasonable efforts to reunify the child(ren) with the Respondent(s) [specify date of finding]: G because of other reasons [specify]: G were not made. This determination is based upon the following information [check applicable box(es)]: G Petition G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: , dated [specify]: G Testimony of [specify]: G 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 2 " non-respondent parent "legal custodian 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]: "is being heard jointly with this proceeding; " is scheduled to be heard on [specify date]: [Applicable to legal custodian or guardian]: Such legal custodian or guardian: " wishes the child(ren) to be released to him/her during the pendency of this proceeding. "Legal custodian" refers to an individual with an order of custody issued prior to, and separate from