Soc. Serv. Law §§ 358-a, 384-a Form 358-a-4 (Temporary Order Approving 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 CIN # Pursuant to Section 358-a of the Social Services Law Docket No. TEMPORARY ORDER APPROVING PLACEMENT INSTRUMENT _______________________________________ 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 NEXT COURT DATE IS [specify date/time]: THE PERMANENCY HEARING SHALL BE HELD ON [specify date/time]:1 The petition of an authorized official of the G Department of Social Services for [specify]: County, G New York City Administration for Children's Services, dated [specify]: , having been filed with this Court requesting that pending any hearing that the Court may require, a temporary order be made approving the transfer of custody and care of the child to the Petitioner, pursuant to Section 358-a(5) of the Social Services Law; and it appearing that a hearing is required and an immediate hearing on notice is impractical; The permanency hearing must be scheduled for a date certain not more than eight months from the date of removal of the child from home. If the child has a sibling or half-sibling removed from the home, whose permanency hearing is scheduled before this Court, the date certain shall be the same as the date certain for the sibling's or halfsibling's permanency hearing, unless the sibling or half-sibling was removed on a juvenile delinquency or PINS petition or unless he or she has permanency hearing shall be cancelled. 1 American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-4 Page 2 [Required findings; check applicable boxes and provide case-specific reasons in A , B and C and, if applicable, D, below]: The Court finds and determines: A. The [check applicable box]: parent(s)[specify]: guardian(s) [specify]: of the child are unable to make adequate provision for the care, maintenance and supervision of the child in the child's own home, based upon the following facts and for the following reasons [specify facts and reasons, including specific documents or evidence supporting findings]: B. 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 determination 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. 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 G parent(s) G guardian(s) [specify date of finding]: G because [specify other reasons]: G were not made. This determination 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]: b . [REQUIRED 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 determination is supported by the following information [check applicable box(es)]: G Case Record, dated [specify]: G Service Plan, dated [specify]: American LegalNet, Inc. www.FormsWorkFlow.com Form 358-a-4 G The report of [specify]: G Other [specify]: , dated [specify]: Page 3 D. [Required in cases involving Native-American children; check if applicable ]: And the following having been duly notified [check applicable box(es)]: parent/custodian tribe/nation United States Secretary of the Interior; And the tribe/nation having: appeared and participated as a party; appeared and declined to assume jurisdiction; appeared and requested transfer of jurisdiction; not appeared; NOW, therefore, upon the basis of the instrument and the allegations of the petition, it is hereby ORDERED that pending a hearing and determination of this matter, the temporary care and custody of the child is transferred to the G Department of Social Services for [specify]: County, G New York City Administration for Children's Services; and it is further [Applicable to Native-American Child(ren); check box(es) if applicable]: ORDERED that the following should be notified of this proceeding [specify]: the custodian of the child; tribe/nation; United States Secretary of the Interior ORDERED that in light of the assumption of jurisdiction by the tribe/nation, this petition is DISMISSED WITHOUT PREJUDICE; (and it is further) ORDERED that this matter be set down for hearing on [specify date/time]: 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: 9Order mailed on [specify date(s) and to whom mailed]:______________________________ 9Order received in court on [specify date(s) and to whom given]:________________________ American LegalNet, Inc. www.FormsWorkFlow.com