Soc. Serv. Law§§ 358-a, 384-a(2)(h) Form 358-a- 6 (Petition for Pre-placement Approval of Standby Placement Instrument) 9/2006 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 PRE-PLACEMENT APPROVAL OF STANDBY PLACEMENT INSTRUMENT CIN # Pursuant to Section 358-A of the Social Services Law ............................................................................................ NOTICE: PLACING YOUR CHILD IN FOSTER CARE MAY RESULT IN LOSS OF YOUR RIGHTS TO YOUR CHILD. 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 shows that: 1. The Petitioner is authorized to file this petition in that (s)he is an official of the Department of Social Services for County and has (his)(her) office and place of business at 2 (a). The above-named child is a (female)(male), born on . (b). The names and addresses of the birth parents or legal guardians of said child are as follows: Name Address (c). The child (is) (is not) a Native-American child subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). American LegalNet, Inc. www.FormsWorkflow.com Form 358-a-6 page 2 (d) The child resides with [specify]: relationship] of the child, at [specify address]: , the [specify . 3. (a) Petitioner has determined that the child is at significant risk of foster care placement during the next 18 months because the (parent)(legal guardian) is suffering from a progressively chronic or irreversibly fatal illness and has no relative or close friend available to designate as a standby guardian. (b) A written instrument, pursuant to Social Services Law §384-a, was executed by [specify]: , the (parent) (legal guardian) of the child, requesting that the child be transferred to the care and custody of [specify authorized agency]: (to reside with [specify prospective foster parent; delete if inapplicable]: ) at such time as the (parent)(legal guardian) dies or becomes debilitated or incapacitated. (c) [Applicable where specific prospective foster parent has been identified in instrument; check applicable box]: The prospective foster parent was found qualified and was certified as a foster parent on [specify date]: . The prospective foster parent has not yet been found qualified and has not yet been certified as a foster parent. The investigation and certification process will be completed by [specify date]: , at which time a report on the outcome will be furnished to all parties, including the law guardian, and to the Court. 4. [Applicable where transfer made pursuant to Section 384-a of the Social Services Law] Pursuant to the attached instrument, (has) (have) consented to the jurisdiction of the Family Court over this proceeding and (has)(have) waived service of the petition and notice of this proceeding. 5. The names and last-known addresses of the child' s parents and all other persons required to be given notice of this proceeding pursuant to Sections 358-a and 384-c of the Social Services Law are: Name Address Relationship and there are no persons other than those set forth who are entitled to notice. 6. No previous application has been made to any court or judge for the relief requested herein, (except .) WHEREFORE, Petitioner requests: American LegalNet, Inc. www.FormsWorkflow.com Form 358-a-6 page 3 A. That process be served on those entitled thereto in accordance with Section 358-a or 384-c of the Social Services Law; and B. That the Court enter an order granting the petition approving the annexed instrument and approving the transfer of custody and (guardianship)(care) to the Social Services official of County, such transfer to take effect when the (parent)(legal guardian) dies, becomes debilitated or incapacitated and a petition pursuant to Section 358-a of the Social Services Law is granted; C. That the Court grant such other and further relief as the Court may deem just and proper. Dated: Petitioner Print or type name and title Signature of Attorney, if any Attorney' s Name ( Print or Type) Attorney' s Address, Telephone # 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. Sworn to before me this day of _____________________ (Deputy)Clerk of the Court Notary Public Petitioner American LegalNet, Inc. www.FormsWorkflow.com