F.C.A. § 661; S.C.P.A.§§ 1701 - 1704 Form 6-1 (Petition for Appointment As Guardian of a Person Or Permanent Guardian) 3/2009 .................................................................. Proceeding for the Appointment of a Guardian of the Person or Permanent Guardian of Docket No. Family File No. PETITION FOR APPOINTMENT AS Guardian of Person Permanent Guardian A Person Under the Age of 21 ................................................................. TO THE FAMILY COURT: The Petitioner respectfully alleges to this Court that: 1. I am [specify relationship]: of the person under the age of 21 who is the subject of this petition and I am submitting this petition in order to be appointed [check applicable box]: Guardian of the Person Permanent Guardian.1 2. My name is [specify]: name and complete address of residence]:2 and I live at [specify 3. The name, date of birth and residence of the person under the age of 21 who is the subject of this proceeding are as follows: Name: Date of Birth: Complete address:3 A "permanent guardian" may be appointed, pursuant to Family Court Act §661(b) and Surrogate's Court Procedure Act §1702(2), if the Court finds that it is in the best interests of a person under the age of 21, who has been committed to an authorized agency through termination of parental rights or surrender or whose birth parents or other persons entitled to notice of, or to consent to, adoption are deceased. Persons over the age of 18 must consent to such an appointment, which may last until the person reaches the age of 21. Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). 3 2 1 American LegalNet, Inc. www.FormsWorkFlow.com Form 6-1 Page 2 4. The subject of this proceeding Gis Gis not a Native American child under the age of 18 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]: 5. The name and relationship of person with whom the subject of this proceeding resides are as follows: Person with whom subject resides [specify name]: Relationship to subject: Address [include street, city, village or town, county and state]:4 6. (Upon information and belief) The religion of the person who is the subject of this proceeding is 7. The names, relationship and post office addresses of the birth parents of the subject of the proceeding, the name and address of the person with whom the subject resides, if other than the parent(s), on whom process should issue; and such other persons concerning whom the court is required to have information, are as follows: [If either birth parent is dead or has surrendered or has had parental rights terminated (TPR) , so allege; if both parents are dead, indicate nearest adult next of kin]: Relationship Name Complete Address Deceased? TPR? Surrender? Birth mother: Birth father: Person with whom the subject resides, if other than parents: Adult next of kin, if birth parents are dead: Other [specify]: 5 4 Unless the Court has ordered the address to be confidential on the ground that disclosure would pose an unreasonable health or safety risk. See Family Court Act §154-b; Form 21 (available at www.nycourts.gov). Include Mental Hygiene Legal Services, if the subject of the proceeding is mentally retarded or developmentally disabled and has been admitted to a facility, and any person entitled to notice of or consent to the adoption of the subject of the proceeding. 5 American LegalNet, Inc. www.FormsWorkFlow.com Form 6-1 Page 3 8. a. Appointing me as the guardian of the person permanent guardian would be in [subject's name]: best interests and would preserve his/her legal rights because [specify facts regarding the suitability, ability and commitment of the proposed guardian to assume full legal responsibility and raise him/her to adulthood]: b. [Required where appointment of permanent guardian is requested, pursuant to Family Court Act §661(b) or S.C.P.A. §1702(2); delete if inapplicable]: (i) [Check applicable box]: guardianship and custody have been committed to the following authorized agency [specify, include whether by surrender or termination of parental rights and attach certified copies of the orders terminating parental rights or approving the surrenders, as applicable]: both parents of the child, whose consent to or notice of an adoption would have been required, are deceased [attach death certificates]. (ii) The local social services district performed an assessment, as required by S.C.P.A. §1704(8), that recommended the following [specify and attach a copy of the assessment]: 9: [Applicable to cases in which child protective petition or permanency hearing report has been filed regarding the children and in which petitioner is a relative or other non-parent; delete if inapplicable]: a. G A child protective petition, Docket # [specify]: , was filed in Family Court, [specify county]: on [specify date]: alleging that [specify names of respondents on that petition]: neglected or abused the above-named child(ren). The petition resulted in [specify whether finding was made and, if so, the disposition; if the disposition has been adjourned pending a consolidated hearing with this petition, pursuant to F.C.A. §1055-b, so indicate and give next court date]: b. G A permanency report, Docket # [specify]: , pursuant to Article 10-A of the Family Court Act, was filed in Family Court, [specify county]: on [specify date]: indicating a permanency plan of guardianship of the child(ren) with Petitioner in this proceeding. The permanency hearing was adjourned to [specify date]: pending a consolidated hearing with this petition, pursuant to F.C.A. §1089-a. c. The child's birth mother Q has Q has not consented to the award of guardianship to the Petitioner. If not, the following extraordinary circumstances support Petitioner's standing to seek American LegalNet, Inc. www.FormsWorkFlow.com Form 6-1 guardianship of the chil