F.C.A.115, 651; S.S.L. 384-a; D.R.L.70, 71,72 General Form 22 (Petition-Habeas Corpus) 10/2004 FAM IL Y COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................................ ............... In the Matter of a Proceeding under 9 Article of the Family Court Act Docket No. 9 Section of the Social Services Law 9 Section Domestic Relations Law Petitioner, -against- Petition For Writ of Habeas Corpus Respondent ........................................................................ ............... TO THE FAMIL Y COURT: The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner resides has offices at [specify address]: and is the[specify relationship]: of the following child(ren), who (is)(are) the subject(s) ofthis application: Name of Child Date of Birth 2. Respondent resides has offices at [specify address]: , and is the [specify relationship]: of the child(ren). . 3. (Upon information and belief,) [check applicable box(es)]: (T)(t)he above child(ren) (is)(are) in the custody of the Respondent and (has)(have) been since [specify date]: . Respondent wrongfully and unlawfully Qremoved Qwithheld the child(ren) from the custody of the Petitioner in that [specify]: . Respondent wrongfully prevented or interfered with Petitioners visitation rights with thechild(ren) in that [specify]: 4. Petitioner has requested the return of the child(ren) from Respondent and Respondent has failed American LegalNet, Inc. www.USCourtForms.com>>>> 2 General Form 22 page 2 and refused to return the child(ren) to the custody of the Petitioner. [Delete if inapplicable]. 5. [Check applicable box(es). Delete inapplicable provisions]: a. G The father of the child(ren) who (is)(are) the subject(s) of this proceeding is [specify]: . G The father was married to the child(ren)s mother at the time of the conception or birth. G An order of filiation was made on [specify date and court and attach true copy]: G Anacknowledgment of paternity was signed on [specify date]: by [specifywho signed and attach a true copy]: G The father is deceased. b. G The father of the child(ren) who (is)(are) the subject(s) of this proceeding has not been legally established. c. G A paternity agreement or compromise was approved by the Family Court of County on , , concerning [name parties to agreement or compromise andchild(ren)]: A true copy of the agreement or compromise is annexed hereto. 6. [Applicable to cases in which mother is not a party]: The name and address of the mother is [indicate if deceased or if address ordered to be kept confidential pursuant to Family Court Act 154-b(2) or Domestic Relations Law 254]: 7. During the last five years, each child who is the subject of this proceeding resided at: [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act 154-b(2) or Domestic Relations Law 254]: Name Address Duration (from/to) 8. The name and present address of the person(s) with whom each child resided during the past five years are as follows [specify address or indicate if ordered to be kept confidential, pursuant to Family Court Act 154-b(2) or Domestic Relations Law 254]: Name Address Duration (from/to) 9. Petitioner has has not participated as a party witness other [specify]: in other litigation concerning the custody of the same child(ren) in New York State Other State or other jurisdiction [specify]: . If so, specify type of case,capacity of participation, court, location and status of case: 10. [Check applicable box]: The following person(s) not party to these proceedings have claimed physical custody or visitation rights to the child(ren) as follows: American LegalNet, Inc. www.USCourtForms.com>>>> 3 General Form 22 page 3 I know of no person(s) not a party to the proceedings who claim(s) to have custody or visitation rights with respect to the child(ren) affected by this proceeding. 11. A custody or visitation proceeding concerning the same child(ren) G is G is not pending in New York State. [If pending, give court docket number and status of case]: 12. The custody or visitation of the child(ren) has been determined or agreed upon in the following instruments [specify court, if any, and date and attach true copy of instrument(s)]: G Custody order G Stipulation G Judgment of Divorce G Separation Agreement G Custody or Guardianship Agreement [confirmed by _______________ court] 13. [Check applicable box]: GPetitioner G Respondent obtained custody of the child(ren) on [specify date]: , as follows: 14. a. The child(ren) Q are Q are not the subject(s) of any order, mandate, judgment or decree of any court of competent jurisdiction, nor has any appeal been taken from any such order, mandate, judgment or decree, [delete if inapplicable]: (except [specify, including court, county, date, docket or index number and status]: . b. No court or judge of the United States has exclusive jurisdiction to order the child(ren) released. 15. An Order of Protection of Temporary Order of Protection was issued [check applicable box(es)]: against Respondent against me in the following criminal, matrimonial or Family Court proceeding(s) [specify the court, 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]: 16. [Check applicable box]: The custody of the child(ren) should be returned to the Petitioner for the following reasons [specify]: Visitation rights should be granted to Petitioner for the following reasons [specify]: 17. The subject child(ren) are are not Native-American child(ren) subject to the Indian Child Welfare Act of 1978 (25 U.S.C. 1901-1963). American LegalNet, Inc. www.USCourtForms.com>>>> 4 General Form 22 page 4 WHEREFORE, Petitioner requests that a Writ of Habeas Corpus be directed to the Respondent(s), commanding the Respondent(s) to produce the child(ren) in this Court, in order that (s)he may be given the custody visitation rights to the child(ren). Petitioner Print or type name Signature of Attorney, if any Attorneys Name (Print or Type) Attorneys Address and Telephone Number VERI FICATION STA TE OF NEW YORK ) )SS.: COUNTY OF ) being duly sworn, says that (he)(she) (they) (is)(are) thePetitioner(s) in the above-named proceeding and that the foregoing petition is true to (his)(her)(their) ownkn