Soc. Serv. Law §§ 358-a, 384, 384-a, 384-c Form 358-a- 1 (Petition for Approval of a Placement Instrument) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................. In the Matter of the Application for Approval of an Instrument concerning Docket No. PETITION FOR APPROVAL OF A 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. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges upon information and belief: 1. The Petitioner is authorized to file this petition in that (s)he is an official of the G Department of Social Services for [specify]: County G New York City Administration for Children's Services, having (his)(her) office and place of business at [specify]: 2. a . The above-named child is a male female , who was born on [specify]: b. The names and addresses of the birth parent(s) or legal guardian(s) of the child are as follows: Name Address 3. On [specify date]: [specify]: , the child was removed from the home of , pursuant to a written instrument executed pursuant American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-1 page 2 to Social Services Law [check applicable box]: 384 384-a(1) 384-a(2)(h)1 on [specify date]: by [specify who executed the instrument and relationship(s) to child]: A copy of the instrument is attached to this petition. 4. (Upon information and belief) The child now resides at [specify]: and is likely to remain in the care and custody of the Department of Social Services for a period in excess of thirty (30) consecutive days. 5. (Upon information and belief) [Specify name(s)]: voluntarily executed the attached instrument because (he)(she) (they) (is)(are) unable to make adequate provision for the care, maintenance and supervision of the child in (his)(her)(their) own home for the reasons that [specify]: 6. (Upon information and belief) Continuation of the child in, or return of the child to, the child's home would be contrary to the best interests of the child because [specify facts and reasons]: This assertion is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: 7. a. Reasonable efforts, where appropriate, to prevent or eliminate the need for placement, and, if the child was removed prior to the date of the hearing, to return the child home safely [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 authorized agency was not required to make reasonable efforts to reunify the child with the Q parent(s) Q guardian(s) [specify date of finding]: G because [specify other reasons]: G were not made. This assertion is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: A standby placement instrument lasting up to one year in duration, previously approved by the Court, pursuant to Social Services Law §358-a(2)(h)(iii), may provide that the child be transferred into foster care upon the death, debilitation or incapacitation of the parent or legal guardian. See Forms 358-a-6 and 358-a-7. Once the transfer takes place, the status of the child must be reviewed using this form, pursuant to Social Services Law §358-a, and the required "best interests" and "reasonable efforts" findings must be made. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 358-a-1 page 3 G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: b . [Applicable in cases in which the child's permanency plan is adoption, guardianship or permanent living arrangement other than reunification]: Reasonable efforts to make and finalize the permanency plan of [specify]: G were made as follows [specify]: G were not made. This assertion is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: c. The following impediments exist, if any, to the fulfillment of the child's permanency plan [specify, indicating documentary sources of information, if any]: 8. The permanency plan for the child is as follows: reunification with the parent(s) guardian(s) by [specify date]: placement for adoption upon filing of a petition to terminate parental rights by [specify date]: . referral for legal guardianship by [specify name and date]: permanent placement with the following fit and willing relative [specify name]: by [specify date]: permanent placement in the following alternative planned living arrangement [specify]: , with a significant connection to the following adult [specify]: who is [check applicable box]: willing to be a permanency resource for the child under exploration as a permanency resource for the child; OR with a significant connection to an adult not yet identified; upon documentation, available to the Court, that the following compelling reason(s) indicate(s) that it would not be in the child's best interests to return home, be referred for termination of parental rights and adoption, placed with a fit and willing relative, or placed with a legal guardian [specify compelling reason(s)]: 9. [Required where child is 14 years of age or older]: (Upon information and belief) The services needed, if any, to assist the child to make the transition from foster care to independent living are [specify]: American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-1 page 4 10. [Applicable where transfer was made pursuant to section 384-a of the Social Services Law] (Upon information and belief) Care and custody of the child has been transferred to the Department of Social Services by means of an instrument executed pursuant to section 384-a of the Social Services Law, and all of the requirements of such section hav