F.C.A. §1074 Form 10-16 (Child Protective - Order Releasing Agency and Changing 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 , . Present: Hon. Judge ......................................................................... In the Matter of Docket No. ORDER ON PETITION FOR RELEASE OF RESPONSIBILITY UNDER ORDER OF PLACEMENT CIN # A Child Under Eighteen Alleged to be GAbused GNeglected by 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 If the child remains in foster care, the permanency hearing must be scheduled for a date certain, in most cases on the previously-scheduled date, not more than eight months from the date of removal of the child from home or within six months of the last permanency hearing. If this Order grants the agency's petition for release from responsibility and the child is discharged, the previously-scheduled date should be cancelled. If the child is not discharged, the permanency hearing may be scheduled to coincide with a new dispositional hearing, so long as notices are given as required by Family Court Act §1089. 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 halfsibling was removed on a juvenile delinquency or PINS petition or unless he or she has been freed for adoption. 1 American LegalNet, Inc. www.FormsWorkFlow.com Form 10-16 Page 2 An Order, dated , having been made herein placing the above-named child in the custody of [specify]: , an authorized agency; and a petition, sworn to on , having been filed by the agency for leave to return the child to this Court and for the release of the agency from responsibility under the Order of Placement; and The matter having duly come on to be heard; and the following having appeared [specify]: and good cause therefore having been shown; it is G ORDERED that the authorized agency is granted leave to return the child to the Court and, upon such return, the agency is released from any further responsibility under the Order of Placement; and it is further G ORDERED that upon the return of the child(ren) to this Court [specify]: OR G ORDERED that the Petition for Release from Responsibility Under Order of Placement is DENIED. . ENTER _____________________________________ Judge of the Family Court Dated: 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: Order mailed on [specify date(s) and to whom mailed ]:___________________________ Order received in court on [specify date(s) and to whom given]:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com