F.C.A. §§ 1012, 1031 Form 10-6 (Child ProtectivePetition -- Neglect) (9/2006) FAMILY COURT OF NEW YORK COUNTY OF ...................................................................................... In the Matter of Docket No. CIN # (A) Child(ren) under Eighteen Years of Age Alleged to be Neglected by PETITION (Child Neglect) Respondent(s) .................................................................................... NOTICE: IF YOUR CHILD IS PLACED IN FOSTER CARE, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. 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. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner [specify]: is a [check applicable box]: “ duly authorized agency having its office and place of business at [specify]: “ person directed by the Court to originate this proceeding, who resides at [specify]: 2. The child(ren) who (is) (are) the subject(s) of this proceeding (is)(are): Sex Date of Birth Custodial Parent/Guardian Child’s Address1 Name 3. a. (Upon information and belief) The father and mother of the child(ren) and their respective residence addresses are: Name of Child(ren) Name of Parent Parent’s Address2 1 Unless ordered confidential, pursuant to Family Court Act §154-b, because of a risk that disclosure would place the health, safety or liberty of the child at risk. 2 See footnote 1. American LegalNet, Inc. www.FormsWorkflow.com Form 10-6 Page 2 b. (Upon information and belief) The person(s) legally responsible for the care of said child(ren) (is)(are)[specify]: who reside at [specify address]:3 4. (Upon information and belief) The child(ren) (is) (are) a(n) neglected on the following grounds and based upon the following facts [Specify grounds of child neglect under Family Court Act §1012, as well as supporting facts]: 5. (Upon information and belief), Respondent(s) [specify]: , the {specify relationship]: child(ren), (is)(are) the person(s) who (is)(are) responsible for the neglect of the child(ren). of the 6. [Required if removal has occurred or is requested; check applicable box(es)]: a. Q (Upon information and belief) On [specify date]: , the following child(ren)[specify]: were temporarily removed from the care of the following Respondent(s) [specify]: on the basis of the following facts and for the following reasons [specify]: in accordance with [check applicable box]: Q a court order pursuant to Family Court Act §1022, issued on [specify]: Q consent of the following Respondent(s) [specify]: on [specify date]: pursuant to Family Court Act §1021.4 Q on an emergency basis without a court order pursuant to Family Court Act There was no time to obtain a court order because [specify]: obtained §1024. b. Q (Upon information and belief) The child(ren) should be removed from the care of the following Respondent(s) [specify]: in accordance with Family Court Act §1027 in order to prevent imminent risk to the child(ren)’s life or health on the basis of the following facts and for the following reasons [specify]: 7. [Required if removal or continued removal of children is requested]: a. (Upon information and belief) Continuation in, or return to, the child(ren)'s home would be contrary to the best interests of the child(ren) because [specify facts and reasons]: This assertion is based upon the following information [check applicable box(es)]: G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: 3 See footnote 1. 4 A copy of the consent instrument must be attached to the petition. See F.C.A. §1021. American LegalNet, Inc. www.FormsWorkflow.com Form 10-6 Page 3 b. (Upon information and belief) Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the child(ren) from the home [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 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 [specify other reason(s)]: G were not made. This assertion is based upon the following information [check applicable box(es)]: G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: c. (Upon information and belief) Based upon Petitioner’s investigation [Check applicable box(es]: “ The following person [specify]: is a “ non-respondent parent “ relative “ suitable person with whom the child(ren) may appropriately reside. [Applicable to relatives and other suitable persons]: Such person: “ seeks approval as a foster parent in order to provide care for the child(ren); “ wishes to provide care and custody for the child(ren) without foster care subsidy during the pendency of any order herein. “ may be a resource but not yet determined whether as a foster parent or custodian. “ There is no non-respondent parent, relative or suitable person with whom the child(ren) may appropriately reside. d. (Upon information and belief) Imminent risk to the child(ren) “ would “ would not be eliminated by the issuance of a temporary order of protection or order of protection directing the removal of [specify]: from the child(ren)'s residence, based upon the following facts and for the following reasons [specify]: 8. The subject child “ is “ is not a Native-American child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicable box(es)]: “ parent/custodian [specify name and give notification date]: “ tribe/nation [specify name and give notification date]: “ United States Secretary of the Interior [give notification date]: American LegalNet, Inc. www.FormsWorkflow.com Form 10-6 Page 4 9. [Required if removal or continued removal of children is requested]:5 Petitioner is required to obtain education information and to provide that information to foster care providers and other parties to this proceeding. Unless otherwise obtained by release, Petitioner thus seeks a court order to obtain the education records (including special education and early intervention records) of each child named in this Petition who is not placed with a parent(s)/legal guardian(s), and a court order to provide such records to service providers where such records are necessary to enable the service provider to establish and implement a plan of service. WHEREFORE, Petitioner requests that an order be issued determining the child(ren) to be neglected and otherwise dealing with the child(ren) in accordance with the provisions of Article 10 of the Family Court Act. Dated , . __________________________________________ Petitioner __________________________________________ Print or Type Name __________________________________________ Signature of Attorney, if any __________________________________________ Attorney’s Name (print or type) __________________________________________ __________________________________________ __________________________________________ Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK ) )ss.: COUNTY OF ) 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 5 This notice is required by the federal Family Educational Rights and Privacy Act [20 U.S.C. §1232(g)(b)(2)(B)].