8 U.S.C. §1101 GF-42 (Special Immigrant Juvenile Status Order) At a Term of the Family Court of the State of New York, held in and for the County of _____ at ______________, New York on_______________ , __. PRESENT: Hon. --------------------------------------------------x Docket No. Family File No. ORDER-Special Immigrant Juvenile Status --------------------------------------------------x This Court, after examining the motion papers and supporting affidavits, all the pleadings and prior proceedings in this matter, and/or hearing testimony, finds, in accordance with 8 U.S.C. § 1101(a)(27)(J), that: 1. The above-named child is under 21 years of age. 2. The above-named child is unmarried. 3. The above-named child is dependent upon the Family Court, or has been committed to or placed in the custody of a state agency or department, or an individual or entity appointed by the state or Family Court. 4. Reunification with one or both of his/her parents is not viable due to [check applicable box(es)]: G abuse; G neglect; G abandonment; and/or G a similar basis under New York law because [specify the basis for the determination]: ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ 5. It is not in the child’s best interest to be removed from the United States and returned to [specify country]: _______________, his/her country of nationality or country of last habitual residence of the child or of his/her birth parent or parents. Dated: ENTER _______________ Judge of the Family Court 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: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:____________________ American LegalNet, Inc. www.FormsWorkFlow.com