Form 10-27 F.C.A §§1054, 10 Page 1 (Child Protective ­ Petition for Extension of Supervision of Respondent and/or Release of Child to Respondent or Non-respondent Parent or Legal Custodian or Guardian) (6/2016) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ----------------------------------------------------------------In the Matter of FAMILY FILE #: CIN # A Child Under Eighteen Years of Age to be Neglected Abused by Respondents Docket No. Family Unit No. PETITION FOR EXTENSION OF SUPERVISION OF RESPONDENT1 RELEASE OF CHILD TO RESPONDENT NON-RESPONDENT PARENT, LEGAL CUSTODIAN OR GUARDIAN .............................................................................. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges upon information and belief that: 1. a. Petitioner, , is the Commissioner of Social Services of [specify]: County an agency duly authorized for the placement of children under Article 10 of the Family Court Act. b. Petitioner's principal office is located at [specify]: , New York. a. By order of this Court, dated [specify]: , the above-named 2. child, who was born on [specify date]: , was found to be neglected abused severely abused repeatedly abused by [specify Respondent(s)]: b. An Order of Disposition, dated [specify]: , [Check all applicable boxes]: placed Respondent [specify]: under the supervision of [specify agency]: until [specify expiration date]: , pursuant to Family Court Act §1057. 1 This form may be used where an order of supervision of the Respondent had been issued together with a release of the child to the Respondent or to a non-respondent parent pursuant to Family Court Act §§1054, 1057. It should NOT be used for an extension of an order of supervision of the Respondent issued together with an order of placement under Family Court Act §1055, since, if the child was placed, the order of supervision extends until the completion of the permanency hearing on the placement and may be continued along with the placement. American LegalNet, Inc. www.FormsWorkFlow.com Form 10-27 Page 2 released the child to the following Respondent parent or other person legally responsible [specify]: until [specify expiration date]: , pursuant to Family Court Act §1057. released the child to the following Non-respondent parent or legal custodian2 or guardian [specify]: until [specify expiration date]: , pursuant to Family Court Act §1054. c. [Check applicable boxes, if any]: By order of this Court, dated [specify]: , the order of supervision of the Respondent was extended for a period of ____ months, terminating on [specify]: By order of this Court, dated [specify]: , the order of release of the child was extended for a period of __ months, terminating on [specify]: d. The child currently resides with [specify]: 3. [Check applicable box(es)]: Good cause exists for this Court to extend the period of supervision3 of the Respondent for a period of ____ months, terminating on [specify date]: for the following reason(s) [specify]: Good cause exists for this Court to extend the period of release4 of the child to the Respondent Non-respondent parent or legal custodian or guardian, for a period of ____ months, terminating on [specify date]: for the following reason(s) [specify]: 4. No previous application has been made to any court or judge for this relief (except [specify; Check applicable box]: ). WHEREFORE, Petitioner requests that this Court conduct a hearing, make a finding of good cause to extend the period of supervision release, enter an order extending the period of supervision release for a period of ____ months, pursuant to Section [check applicable box]: 1054 1057 of the Family Court Act, and grant such other and further relief as the Court deems appropriate, including, but not limited to, the following [specify]: Dated: , . ______________________________________ Petitioner ______________________________________ Print or Type Name ______________________________________ Attorney, if any ______________________________________ "Legal custodian" refers to an individual with an order of custody issued prior to, and separate from, the child protective proceeding. A release to such an individual is distinguished from a child placed in the custody of an individual pursuant to an order of custody issued under Article 6 and section 1055-b of the Family Court Act. Such a custody order results in the termination of all orders under Article 10 of the Family Court Act, would not be deemed a "release" of the child and would thus not be the subject of an extension petition. 3 The total period of supervision, including the original period and any extensions, cannot exceed two years. 4 The total period of release, including the original period and any extensions, cannot exceed two years. American LegalNet, Inc. www.FormsWorkFlow.com 2 Form 10-27 Attorney's Name (print or type) ______________________________________ ______________________________________ ______________________________________ Attorney's Address and Telephone Number Page 3 VERIFICATION STATE OF NEW YORK COUNTY OF ) ) ss.: ) __________________________________ being duly sworn, deposes and says: that (s)he is and is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)he has read the foregoing petition and knows the contents thereof; that the same is true to (his(her) own knowledge except as to those matters therein stated to be alleged upon information and belief, and that as to those matters (s)he believes it to be true. _________________________________ Petitioner Sworn to before me this ______ day of _____________ _________________________ (Deputy)(Clerk of the Court) (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com