General Form 17 Page 1 FCA 247247 467, 549, 651, 652,654; DRL 24724775 - l, 240 1 Pe tition - Custody, V isitation) 3/2018 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ..................................................................................... In The Matter of a Proceeding for Custody Visitation under Article 4 5 6 of the Family Court Act or Section 240 of the Domestic Relations Law Family Fi le No. Petitioner Docket No. Relationship to child: PETITION CUSTODY VISITATION - against - Respondent Relationship to child: ....................................................................................... TO THE FAMILY COURT: The Petitioner respectfully alle ges upon information and belief that: 1. The name, gender, current address and date of birth of ea ch child who is the subject of this proceeding are as follows [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act 247154 - b(2) or Domestic Relations Law 247254]: 1 Note : If a custody or visitation proceeding is pending in, or an order of custody or visitation has been issued by, a court outside of the State of New York, including a Native - American tribunal, the custody/vis itation petition for proceedings under the Uniform Child Custody Jurisdiction and Enforcement Act, Form UCCJEA - 1 should be utilized instead of this form. If a prior order of custody or visitation had been entered by a Court of this State, the petition for modification or enforcement, General Forms 40 or 41, should be used instead of this form. Name Gender Date of Birth Current Address Name of Person with Whom Child Resides 2. a. Petitioner, , [check applicable box]: resides is located at [specify address or in dicate if ordered to be kept confidential pursuant to Family Court Act 247154 - b(2) or Domestic Relations Law 247254]: b. Petitioner is [specify relationship to child; if foster parent, agency, institution or other relationship, so state]: 3. a. Respondent, , [check applicable box]: resides is located at [specify address or indicate if ordered to be confidential, pursuant to Family Court Act 247154 - b(2) or Domestic Relations Law 247254]: American LegalNet, Inc. www.FormsWorkFlow.com General Form 17 Pag e 2 b. Respondent is [specify relationship to child; if foster parent, agency, inst itution or other relationship, so state]: 4. [Check box if applicable, or if not, SKIP to 2665] (Upon information and belief) For any child listed in 266(1) above who resided at the current address and/or with the current person for two years or less , specify where and with whom the child lived during the two years prior to that time [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act 247154 - b(2) or Domestic Relations Law 247254]: Name of Child Duration Name of Person Current Address ( from/to) With Whom Child of the Person With Resided Whom Child Resided 5 . [Applicable when Petitioner and/or Respondent is on active military duty or has recently returned from active military service; check box(es) if applicable, or if not, SKIP to Paragraph 6]: a. Petitioner is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, m ilitary branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]: 2 Petitioner returned from active duty, deployment or temporary assignment to military service as follows [specify date of return, type of service, military branch or National Guard unit and how return from duty is likely to affect custody or visitation, if at all]: b . Respondent is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, military branch or National Guard unit and how return from duty is likely to affect custody or visi tation, if at all]: 3 Respondent returned from active duty, deployment or temporary assignment to military service as follows [spe cify date of return, type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]: 5. [Check box(es) if applicable; or if not, SKIP to Paragraph 6]: An order was issued by Court, County, State of , referring the issue of custody visitation to the Family Court of the State of New York in and for the County of [specify]: 2 Inapplicable if Petitioner is based at a permanent duty station or has had a permanent reassignment of stati on. 3 Inapplicable if Respondent is based at a permanent duty station or has had a permanent reassignment of station. 6. [Check applicable box(es)]: a. The father of the child(ren) who (is)(are) the subject(s) of this proceeding is [specify]: s mother at the time of the conception or birth. An order of filiation was made on [specify date and court and attach true copy]: American LegalNet, Inc. www.FormsWorkFlow.com 3 General Form 17 Page 3 An acknowledgment of paternity was signed on [specif y date]: by [specify who signed and attach a true copy]: The father is deceased. b. The father of the child(ren) w ho (is)(are) the subject(s) of t his proceeding has not been legally established. c. A paternity agreement or compromise, pursuant to former Family Court Act 247516, 4 was approved by the Family Court of County on , , concernin g [name parties to agreement or compromise and child(ren)]: A true copy of the agreement or compromise is attached to this petition. 7. [Applicable to cases in which either parent is not a party; check box if applicable, or if not, SKIP to Paragraph 8] : The name and address of a parent or parents who are not parties to this proceeding are: [specify; indicate if deceased or if address(es) ordered to be kept confidential pursuant to Family Court Act 247154 - b(2) or Domestic Relations Law 247254]: 8. [Check box if applicable, or if not, SKIP to Paragraph 9]: Petitioner has participated as a party witness other capacity [specify]: in other litigation concerning the custody of the same children in New York State Other jurisdiction [specify]: 5 If so, specify type of case, type of participation, court, location and status of case. 9. a. A custody or visitation proceeding concerning the same child(ren) is is not pend ing in New York State. [If pending, give court docket number and status of case]: b. A custody or visitation proceeding concerning the same child(ren) is is not pending in a jurisdiction outside New York State. [If pending, specify where, cou rt docket number and status of case]: 10. [Check box if applicable, or if not, SKIP to Paragraph 11]: The custody or visitation of the child(ren) has been agreed upon in the following custody, separation or guardianship agreement, dated [specify, and attach copy]: 11. [Check box (es) if applicable, or if not, SKIP to Paragraph 12]: a. Petitioner Respondent obtained custody of the child(ren) on [specify date]: , as follows: b. Petitioner Respondent obtained visitation with the child(ren) on [specify date]: , as follows: 4 The agreement or compromise must have been signed prior to the repeal of FCA 247516 on May 19, 2009. 5 If litigation occurred in Native - American tribunal, so indicate. American LegalNet, Inc. www.FormsWorkFlow.com 4 General Form 17 Page 4 12. It would be in the best interests of the child(ren) for Petitioner to have custody visitation for the following reasons [specify]: 13. [Check box(es) if applicable, or i f not, SKIP to Paragraph 14]: a. An Order of Protection or Temporary Order of Protection was issued [check applicable box(es]: against Respondent against me in the following criminal, matrimonial and/or Family Court proceeding(s) [specify the co urt, docket or index number, date of order, next court date and status of case, if available]: The Order of Protection Temporary Order of Protection expired or will expire on [specify date ]: b. Petitioner requests a Temporary Order of Protection pursuant to Family Court Act 247655 because [specify]: 14. [Applicable where one or more parties are not par ents of the child(ren); if not, SKIP to Paragraph 15]: The subject child(ren) are are not Native - Ame