F.C.A § 1065 Form 10-12 (Child Protective – Order on Motion to Terminate Placement) (8/2010) 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 under Eighteen Years of Age Alleged to be “Abused “Neglected by Docket No. ORDER ON MOTION TO TERMINATE PLACEMENT Respondent(s) .............................................................................. 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 PERMANENCY HEARING SHALL BE HELD ON [Specify date/time]:1 The motion of [specify]: , dated [specify]: accompanied by a sworn affidavit of {specify]: , dated [specify]: having been duly filed with this Court, requesting termination of the placement of [specify child]: with [specify with whom child placed]: NOW, after examination and inquiry into the facts and circumstances and Gafter hearing the 1 Inapplicable if motion to terminate placement is granted. Insert a date, in most cases the previouslyscheduled date, not more than eight months from removal of the child or six months from the completion of the most recent permanency hearing. If the child has been placed and 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 or adoption. American LegalNet, Inc. www.FormsWorkFlow.com Form 10-12 Page 2 proof and testimony offered in relation thereto; it is therefore [check applicable box(es)]: G ORDERED that the motion is GRANTED, the placement of the above-named child is terminated and the child shall be discharged to the care and custody of [specify]: OR G ORDERED that the motion is DENIED and Gmay Gmay not be renewed for a period of at least 90 days; (and it is further) G ORDERED that the child shall be discharged to the care and custody of [specify]: according to the following schedule [specify]: (and it is further) G ORDERED that the care and custody of the child shall be transferred to the following agency [specify]: (and it is further) G ORDERED that the G Commissioner of Social Services G Other agency [specify]: shall take the following steps regarding the child’s care and welfare [specify]: (and it is further) G ORDERED that the GOrder of Disposition GPermanency Hearing Order, dated [specify]: is modified as follows [specify]: (and it is further) [If motion denied]: G ORDERED that the permanency hearing will take place on [specify date certain, in most cases the previously-scheduled date]:2 [If motion granted]: G ORDERED that the previously-scheduled permanency hearing is cancelled. G ORDERED that ENTER Dated: , _____________________________________ Judge of the Family Court PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. Check applicable box: G Order mailed on [specify date(s) and to whom mailed ]:___________________________ G Order received in court on [specify date(s) and to whom given]:_____________________ 2 See footnote 1. American LegalNet, Inc. www.FormsWorkFlow.com