F.C.A.§115; S.S.L. §39(6) General Form 19 (Petition-Transfer of Indian Child) 8/2002 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .......................................................................................... In the Matter of a Proceeding [specify] under [specify statute]: Docket No. Child's Name: Date of Birth: ........................................................................................... TO THE FAMILY COURT PETITION FOR TRANSFER OF PROCEEDING CONCERNING AN INDIAN CHILD The undersigned Petitioner respectfully alleges upon information and belief that: 1. The child, [specify]: , is an Indian child as defined in subdivision 36 of section 2 of the Social Services Law, and is the subject of the above-entitled proceeding, which involves the 9 foster care placement of 9 termination of parental rights to the child. 2. The Petitioner, [specify]: resides at [specify address]: , and is the [check applicable box]: 9 father 9 mother 9 Indian custodian of the child 9 Chief of the [specify tribe]: , an Indian tribe designated by the 9 Bureau of Indian Affairs of the Federal Department of the Interior 9 State of New York. 3. The Indian child is a member of the tribe and is not domiciled or residing within the tribal reservation. WHEREFORE, Petitioner requests the transfer of the proceeding to the jurisdiction of the Indian tribe and for such other and further relief as the Court may determine. Dated: , . Petitioner Print or type name Signature of attorney, if any Attorney's Name (Print or Type) Attorney's Address and Telephone Number American LegalNet, Inc. www.USCourtForms.com General Form VERIFICATION STATE OF NEW YORK COUNTY OF ) )SS.: ) 19 Page 2 being duly sworn, says that (s)he is the Petitioner in the above-named proceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. Petitioner Sworn to before me this day of , (Deputy)(Clerk) of the Court Notary Public American LegalNet, Inc. www.USCourtForms.com