Soc. Serv. Law §§ 384-b; F.C.A. §1089 Form TPR-11 (Order of Disposition-Severe or Repeated Child Abuse 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 Commitment of Guardianship and Custody pursuant to section 384-b of the Social Services Law of CIN # A Child under the Age of Eighteen Years, alleged to be a ❑Severely ❑Repeatedly Abused Child ____________________________________ Docket No. FINDINGS OF FACT, CONCLUSIONS OF LAW AND ORDER OF DISPOSITION (Severe or Repeated Child Abuse) THE NEXT PERMANENCY HEARING SHALL BE HELD ON [specify date/time]:1 A Petition under Section 384-b of the Social Services Law, dated [specify]: , having been filed in this Court alleging that [specify]: is a [check one or both boxes]: ❑severely ❑ repeatedly abused child; and summonses having been issued and duly served upon and notice having been duly given to all proper parties hereto, and ❑ Respondent #1 [specify]: having ❑ appeared ❑ with counsel ❑ without counsel ❑ waived counsel ❑ not appeared; And Respondent #1 [specify]: having: ❑ voluntarily, intelligently and knowingly admitted in open court that (s)he committed the following act(s) [specify]: ❑ denied the allegations of the petition and the matter having duly come on for a factfinding hearing before this Court ; 1 Respondent is NOT a party to the permanency hearing if his or her rights have been terminated. Unless the petition is dismissed or the child is returned home, the permanency hearing must be scheduled for a date certain within 30 days of the earlier of this Court’s announcement of its decision or issuance of this Order. The next permanency hearing must be scheduled for a date certain not more than six months after the completion of the permanency hearing. A separate permanency order, Form PH-6, must be issued even if the permanency hearing is combined with the dispositional hearing in this proceeding. American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-11 Page 2 ❑ failed to appear and the matter having duly come on for a fact- finding hearing by inquest before this Court; ❑ Respondent #2 [specify, if any]: having ❑ appeared ❑ with counsel ❑ without counsel ❑ waived counsel ❑ not appeared; And Respondent #2 [specify, if any]: having: ❑ voluntarily, intelligently and knowingly admitted in open court that (s)he committed the following act(s) [specify]: ❑ denied the allegations of the petition and the matter having duly come on for a factfinding hearing before this Court ; ❑ failed to appear and the matter having duly come on for a fact- finding hearing by inquest before this Court; And the child having been represented by an attorney; [Required where only one parent or non-parent is Respondent; check if applicable]: ❑ The legal status of the other parent(s) [specify]: is/are as follows [specify if rights retained, terminated, surrendered or if parent is deceased or whereabouts unknown]: [Required in cases involving Native-American children; check if applicable]: ❑ And the following having been duly notified [check applicable box(es)]: ❑ parent/custodian2 ❑ 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; And the matter having duly come on for a fact-finding hearing , the Court, after [check box] ❑ hearing the proofs and testimony offered in relation to the case ❑ accepting the admission by Respondent(s) [specify]: finds that the allegations of ❑severe abuse ❑ are ❑are not ❑ repeated abuse ❑ are ❑are not supported by clear and convincing evidence, and the Court further makes the following findings of fact by clear and convincing evidence and comes to the following conclusions of law: FINDINGS OF FACT [insert] CONCLUSIONS OF LAW [insert] The matter having duly come on for a dispositional [check box if applicable]: 2 Notice to parent is not required if parental rights were terminated. American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-11 Page 3 ❑ and permanency hearing, and ❑ Respondent [specify]: having ❑ appeared ❑ with counsel ❑ without counsel ❑ waived counsel ❑ not appeared; ❑ Respondent [specify]: having ❑ appeared ❑ with counsel ❑ without counsel ❑ waived counsel ❑ not appeared; before this Court for the dispositional [check box if applicable]: ❑ and permanency hearing; and [Applicable in cases where guardianship and custody are committed to an authorized agency or where judgment is suspended]: The Court having determined that the following individual(s) would be entitled to notice of an adoption pursuant to Domestic Relations Law §111-a [specify name(s)]: And the Court having determined that such person(s) ❑ had ❑ had not been provided with notice of the proceeding and that such person(s) ❑ had ❑ had not appeared; ❑ [Required if Child is 14 or older]: The above-named child, who was born on [specify]: ❑ has consented to adoption by [specify]: ❑ has withheld consent to adoption by [specify]: for the following reasons [specify, including information furnished by the attorney for the child and/or child]: The Court, having made examination and inquiry into the facts and circumstances of the case and into the surroundings, conditions and capacities of the persons involved in this proceeding, finds that the best interests of the child require the disposition made below; NOW, therefore, it is ❑ ORDERED AND ADJUDGED that [specify]: is a [check applicable box]: ❑ severely ❑ repeatedly abused child as defined in subdivision eight of section 384-b of the Social Services Law; OR ❑ ORDERED AND ADJUDGED that [specify]: is NOT a [check applicable box]: ❑ severely ❑ repeatedly abused child as defined in subdivision eight of section 384-b of the Social Services Law and the petition is DISMISSED; (and it is further) [Check applicable box(es)]: ❑ ORDERED that the guardianship and custody rights of [specify]: are transferred to [specify]: , ❑ an authorized agency ❑ foster parent(s); and such guardianship and custody of the child are committed to the ❑ authorized agency ❑ foster parent(s) upon the following terms and conditions [specify]: ❑ And it is further ORDERED that [specify]: is authorized and empowered to consent to the adoption of the child subject to the order of a Court of competent jurisdiction to which a petition for adoption is submitted without the consent of or further notice to [specify]: , the [specify relationship to the child]: OR ❑ ORDERED that judgment is suspended pursuant to Section 384-b(8)(f) upon the following American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-11 Page 4 terms and conditions until the following date [specify date up to one year after the Order]:3 ; Applicable where guardianship and custody have been transferred to the Petitioner □AND IT IS FURTHER ORDERED that the Petitioner herein shall forthwith advise the preadoptive foster parents(s) of his/her/their right to file an adoption petition in a court of competent jurisdiction and further advise the pre-adoptive foster parent(s) as to all necessary supporting documents; □AND IT IS FURTHER ORDERED that a certified copy of this order be filed for recording at the Office of the County Clerk in accordance with the provisions of Section 384-b of the Social Services Law; Applicable Where Child is Native-American ❑ 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 proceeding is DISMISSED WITHOUT PREJUDICE. Required Date Certain for Permanency Hearing [Required in all cases in which the child is in the guardianship and custody of the authorized agency or foster parent]: ORDERED that if the child remains in the custody and guardianship of the authorized agency or foster parent, the next permanency hearing shall be held on [specify date certain within 30 days of the earlier of the Court’s announcement of its decision or issuance of this Order]: And it is further ORDERED that Petitioner shall transmit notice of the hearing and a permanency report no later than [check applicable box]: ❑ 14 days in advance of the above date certain ❑ other date [specify]: to all parties, attorneys, the attorney for the child and any pre-adoptive parent or relative providing care to the child(ren) and shall transmit notice of the hearing to former foster parent(s) who have had care of the child(ren) in excess of 12 months. □AND IT IS FURTHER ORDERED that ENTER Dated: , . _____________________________________ 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: □ Order mailed on [specify date(s) and to whom mailed ]:___________________________ □ Order received in court on [specify date(s) and to whom given]:_____________________ 3 See 22 N.Y.C.R.R. §205.50. If judgment is suspended, add the suspended judgment provisions of Form TPR-2a, as well as a copy of the court rule, to this Order. American LegalNet, Inc. www.FormsWorkFlow.com