Soc. Serv. Law§§ 384-b, 384-c FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................. In the Matter of the Commitment of Guardianship and Custody pursuant to § 384-b of the Social Services Law of Form TPR-6 (Termination of Parental Rights- Abandonment Petition) (8/2010) Docket No. PETITION CIN # (ABANDONMENT) A Child under the Age of Eighteen Years, alleged to be an Abandoned Child ............................................................................................... IF THIS PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT AND WITHOUT NOTICE TO YOU. IF YOU ARE THE PARENT, FOSTER PARENT OR CUSTODIAN OF THE CHILD, YOU HAVE A RIGHT TO HAVE A LAWYER REPRESENT YOU. IF YOU CANNOT AFFORD A LAWYER, YOU MAY ASK THE COURT TO APPOINT A LAWYER TO REPRESENT YOU WITHOUT FEE. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner(s) , (is) (are) □ an authorized agency having its office and place of business at [specify, including county]: □ foster parent(s) residing at [specify, including county]: □ child’s attorney □ guardian ad litem filing at the Court’s direction, pursuant to Social Services Law §384-b(3)(b). 2 a. is a □male □female child under the age of eighteen years, born on [specify]: , at [specify]: , who now resides at [specify, including county]: . b. The subject child ❑ is ❑ is not a Native-American child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicable box(es)]: ❑ parent/custodian [specify name and give notification date]: ❑ tribe/nation [specify name and give notification date]: ❑ United States Secretary of the Interior [give notification date]: 3. The full name and last-known address of each parent and custodian of the child, if known, are: Name Last-Known Address 4. a. The name and last-known address of any other interested party who should be afforded notice of this proceeding are: American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-6 Name Page 2 Last-Known Address b. The name and last-known address of any other person entitled to notice of an adoption pursuant to Domestic Relations Law § 111-a are: Name Last-Known Address c. There are no persons other than those set forth entitled to notice of this proceeding or of an adoption of the child. 5. The child came into the care of an authorized agency on [specify]: , under the following circumstances: [include court, county, docket number and date(s) of prior proceedings; if the child was abandoned at the age of five days or younger and a finding of aggravated circumstances was made, so indicate, including date]: 6. (Upon information and belief) (T)(t)he respondent(s), □ father □ mother (has)(have) evinced an intent to forego (his)(her)(their) parental rights and obligations as manifested for the period of six months immediately prior to the initiation of this proceeding by [specify]: 7. The parent(s) (was) (were) able to communicate and visit and were not prevented nor discouraged from doing so by the agency. 8. The best interests of the child require the commitment of the guardianship and custody of the child to □ an authorized agency □ foster parent(s) for the following reasons [specify; if appropriate, include facts regarding a non-respondent parent]: 9. The child ❑ is ❑is not under the jurisdiction of the Family Court. If so, this petition ❑ has ❑ has not been filed in the Court that exercised jurisdiction over the most recent permanency or other proceeding involving this child. [If it has not been so filed, petitioner must file affirmation, Form TPR12]. 10. No previous application has been made to any court or judge for the relief sought herein (except [specify]: WHEREFORE, the Petitioner requests an order determining that the above-named child is an abandoned child, and committing the guardianship and custody of the child to □ an authorized agency □ foster parent(s), and for such other and further relief as in the interests of the child may be granted. Dated: . □ Agency by: Name Title □ Foster parent: Print or type name American LegalNet, Inc. www.FormsWorkFlow.com Form TPR-6 Page 3 Signature of Attorney, if any Attorney’s Name (Print or Type) Attorney’s Address and Telephone Number VERIFICATION (Agency) STATE OF NEW YORK COUNTY OF ) ss.: ) being duly sworn, deposes and says: That (he) (she) is a duly constituted official of the above-named authorized agency, to wit, its ; That (he) (she) has read the foregoing Petition and knows the contents thereof; that the same is true to (his) (her) own knowledge except as to matters therein stated to be alleged on information and belief and that as to those matters (he) (she) believes it to be true. Agency Official Sworn to before me this day of , . (Deputy) Clerk of the Court Notary Public VERIFICATION (Individual) ) )SS.: COUNTY OF ) , being duly sworn, says that (s)he is the Petitioner in the above-entitled proceeding and that the foregoing petition is true to (his) (her) own knowledge, except as to matters herein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. STATE OF NEW YORK Petitioner Sworn to before me this day of . (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkFlow.com