Soc. Serv. Law §§ 358-a, 384-a(7)(h) Form 358-a-7 (Order of Disposition Approval of Standby Placement Instrument) 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 the Application for Approval of an Instrument concerning Docket No. ORDER OF DISPOSITION-PETITION FOR APPROVAL OF STANDBY PLACEMENT INSTRUMENT CIN # Pursuant to Section 358-a of the Social Services Law ____________________________________________ NOTICE: 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 THE PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. The Petition of an authorized official of the Department of Social Services, County, dated the day of , , having been filed with the Court requesting approval of an instrument transferring custody and care of the child to the agency, such transfer to take effect upon the death, debilitation or incapacity of the parent or guardian and upon the granting of a petition at that time pursuant to Social Services Law §358-a, [Delete inapplicable provisions; check applicable box(es)]: And the parent guardian having been duly served with notice of this proceeding and any such persons appearing having been given an opportunity to be heard And the parent guardian having by instrument consented to the jurisdiction of this Court and having waived service of the petition and notice of this proceeding and the Court having dispensed with such service, American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-7 Page 2 And an attorney having been appointed and having appeared to represent the child, And the matter having duly come on for a hearing before this Court, and the Court, after hearing the proof and testimony offered in relation to the case, (not being satisfied)) (being satisfied) that the (parent)(guardian) executed such instrument knowingly and voluntarily and because (he)(she) would be unable to make adequate provision for the care, maintenance and supervision of the child in (his)(her) home in the event of (his)(her) death, debilitation or incapacity, Now, therefore, it is hereby [Delete inapplicable provisions]: (ORDERED that the petition is granted and the instrument dated is hereby approved;)(and it is further) OR (ORDERED that the petition is dismissed;) (and it is further) executed by (ORDERED that the transfer of custody (and care) to the Petitioner is hereby approved, such transfer to take effect upon the (death)(incapacity or debilitation) of Petitioner;) (and it is further) (ORDERED that a copy of this Order shall be served (personally) (by certified mail) by the Petitioner upon the (parent(s)) or (guardian(s)) who executed the aforesaid instrument. Such service shall be made within days from the date hereof;) (and it is further) (ORDERED ). 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: 9 Order mailed on [specify date(s) and to whom mailed]:____________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com