F.C.A §§1017, 1027 Form 10-2 (Child Protective -- Order on Application for Temporary Removal of Child After Petition Filed) 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 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 TEMPORARY REMOVAL OF CHILD (After Petition Filed) 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 A Petition under Article 10 of the Family Court Act having been filed with this Court alleging that the above-named child(ren) (is)(are)[check applicable box(es)]: " abused " neglected " severely abused " repeatedly abused ; Specify a date certain not more than eight months from the date of removal. If the child has 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 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 10-2 Page 2 And the child (ren) [check applicable box(es)]: " having been removed prior to this hearing pursuant to Family Court Act [specify]: " §1021 " §1022 " having not been removed prior to this hearing; " §1024 And a preliminary hearing having been held by this Court pursuant to Section 1027 of the Family Court Act; and the following person(s) having appeared to determine whether the child's interests require protection pending a final order of disposition [specify; check applicable boxes]: " Respondent [specify]: " with counsel " without counsel [If Respondent not present]: Respondent " was " was not notified of this hearing. [If Respondent unrepresented]: Respondent " waived " did not waive the right to counsel. " Respondent [specify]: " with counsel " without counsel [If Respondent not present]: Respondent " was " was not notified of this hearing. [If Respondent unrepresented]: Respondent " waived " did not waive the right to counsel. " Attorney for the Child " 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, II and III if temporary removal is GRANTED]: I. Criteria for Temporary Removal of Child(ren) [All three criteria (A, B and C) must be met]: A. [check applicable boxes]: The " parent(s) " person(s) legally responsible for the child(ren) " 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) OR " The child(ren) was/were removed on an emergency basis, pursuant to Family Court Act §1024; 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 American LegalNet, Inc. www.FormsWorkFlow.com Form 10-2 Page 3 AND C. Immediate removal or, if already removed, continued removal, of the child(ren) is necessary to avoid imminent danger to the child(ren)'s life or health because [specify facts and reasons, citing specific documents or evidence supporting findings]: 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, or return 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)]: " Petition " Report of Suspected Child Abuse or Neglect " Case Record, dated [specify]: " Service Plan, dated [specify]: " The report of [specify]: " Testimony of [specify]: " Other [specify]: , dated [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]: " 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 of other reasons [specify]: " were not made. This determination is based upon the following information [check applicable box(es)]: " Petition " Report of Suspected Child Abuse or Neglect " Case Record, dated [specify]: " Service Plan, dated [specify]: " The report of [specify]: " Testimony of [specify]: " Other [specify]: , dated [specify]: III. Findings Regarding Alternatives to Removal to Foster Care: American LegalNet, Inc. www.FormsWorkFlow.com Form 10-2 Page 4 A. Based upon the investigation conducted by the Commissioner of Social Services, [Check applicable box(es]: " The following person [specify]: is a " non-respondent parent " relative " suitable person with whom the child(ren) may appropriately reside [specify]: [Applicable to relat