F.C.A. § 661; S.C.P.A.§§ 1701 - 1704 Form 6-1-a (Petition by Person Over 14 for Appointment Of Guardian of a Person Or Permanent Guardian) 9/2008 .................................................................. Proceeding for the Appointment of a Guardian of the Person or Permanent Guardian of A Person Under the Age of 21 ................................................................. TO THE FAMILY COURT: Docket No. Family File No. PETITION BY PERSON OVER 14 FOR APPOINTMENT OF ”Guardian of Person ”Permanent Guardian The Petitioner respectfully alleges to this Court that: 1. I am a person over the age of 14 and under the age of 21 and I am submitting this petition on my own behalf to request that [specify proposed guardian]: be appointed as my [check applicable box]: ”Guardian of the Person ”Permanent Guardian.1 2. a. I was born on [specify date and year of birth]: b. I live at [specify name and complete address of residence]:2 c. I live with [specify]: who is/are related to me as follows [specify]: 3. a. The name and residence of the proposed guardian are as follows: Name: Complete address:3 1 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. 2 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 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). American LegalNet, Inc. www.FormsWorkflow.com Form 6-1-a Page 2 b. He/She has consented to appointment as guardian, a copy of which is attached. 4. I Gam Gam 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. My religion is [specify, if any]: 6. The names, relationship and post office addresses of my birth parents, the name and address of the person with whom I live, if other than my birth 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 4 Deceased? TPR? Surrender? Birth mother: Birth father: Person with whom I reside, if other than parents: Adult next of kin, if birth parents are dead: Other [specify]: 5 7. a. Appointing [specify proposed guardian]: as the ”guardian of my person ”permanent guardian would be in my best interests and would preserve my legal rights because [specify facts regarding the suitability, ability and commitment of the proposed guardian to assume full legal responsibility and raise you to adulthood]: 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). 5 Include Mental Hygiene Legal Services, if the petitioner is mentally retarded or developmentally disabled and has been admitted to a facility, and any person entitled to notice of or consent to petitioner’s adoption. American LegalNet, Inc. www.FormsWorkflow.com Form 6-1-a Page 3 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]: “ my 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 of my birth parents, whose consent to or notice of my 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]: 8. (Upon information and belief) No guardian pursuant to will or deed, or guardian of the person pursuant to Section 384 or 384-b of the Social Services Law, has been previously appointed for me, except [specify]: 9. Upon information and belief, [Check all applicable box(es)]: a. Q The proposed guardian has never been the subject of an indicated report, as such term is defined in of the Social Services Law §412, that has been filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422. Q The proposed guardian was the subject of an indicated report, as defined in of the Social Services Law §412, that was filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422. [Specify the date of the report, determination of whether “indicated” or “unfounded,” status and circumstances to the extent known]: Q The proposed guardian is the subject of a report, as defined in of the Social Services Law §412, filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422, that remains under investigation. [Specify the date of the report, status and circumstances to the extent known]: b. Q The proposed guardian has never been the subject of, or the respondent in, a child protective proceeding pursuant to Article Ten of the Family Court Act. Q The proposed guardian has been the subject of, or the respondent in, a child protective proceeding pursuant to Article Ten of the Family Court Act. [Specify whether the American LegalNet, Inc. www.FormsWorkflow.com Form 6-1-a Page 4 proceeding resulted in an order finding that a child or children was/were abused or neglected, indicate whether the petitioner was found to be abused or neglected and provide the date and status of the proceeding to the extent known]: c. Q The proposed guardian has never been the subject of an Order of Protection or Temporary Order of Protection in any criminal, matrimonial or Family Court proceeding(s). Q The proposed guardian has been the subject of an Order of Protection or Temporary Order of Protection in a criminal, matrimonial or Family Court proceeding(s) as follows [specify the court, docket or index number, who was protected and who was restrained by the order, date of order, expiration date of order, next court date and status of case to the extent known]: Name 10. Upon information and belief,[check applicable box(es)]: a. The following adults 18 or older live in the proposed guardian’s home: Relationship, if any, to subject of proceeding Date of Birth b. Q None of the adults 18 or older living in the proposed guardian’s home has ever been the subject of any indicated reports, as defined in of the Social Services Law §412, that were filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422. Q The following adults 18 or older living in the proposed guardian’s home have been the subjects of indicated reports, as defined in of the Social Services Law §412, that were filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422. [Specify the name(s) of the adults, date(s) of the report(s), whether petitioner in this proceeding was the subject of the report(s), status and circumstances to the extent known]: Q The following adults 18 or older living in the proposed guardian’s home are the subjects of reports, as defined in of the Social Services Law §412, filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422, that remain under investigation [Specify the name(s) of the adults, whether the subject of this proceeding is the subject of the report(s), date(s) of the report(s), status and circumstances to the extent known]: c. Q None of the adults 18 or older living in the proposed guardian’s home has ever been the subjects of, or the respondents in, child protective proceedings pursuant to Article Ten of the American LegalNet, Inc. www.FormsWorkflow.com Form 6-1-a Page 5 Family Court Act. Q the following adults 18 or older living in the proposed guardian’s home have been the subjects of, or the respondents in, child protective proceedings pursuant to Article Ten of the Family Court Act, as follows [Specify the names of the adults, whether the proceedings have resulted in orders finding that the child is an abused or neglected child, whether the petitioner in this proceeding was a subject of those proceedings and the date and status of the proceedings to the extent known]: d. Q None of the adults 18 or older living in the proposed guardian’s home has ever been the subjects of an Order of Protection or Temporary Order of Protection in any criminal, matrimonial or Family Court proceeding(s). Q the following adults 18 or older living in the proposed guardian’s home have been the subjects of Orders of Protection or Temporary Orders of Protection in criminal, matrimonial or Family Court proceeding(s), as follows [specify the names of the adults, whether the adults are or were restrained or protected by the order(s), court, docket or index number, date of order, expiration date of order, next court date and status of cases to the extent known]: 11. My birth parent(s) [specify]: although living, should not be appointed as my guardian because: 12. a. [Applicable where the petitioner is 18 years of age or older; delete if inapplicable]: I am over the age of 18 and have consented to the appointment of the guardian, a copy of which is attached. b. [Applicable where the child is over 14 years of age but less than 18; delete if inapplicable]: I have expressed a preference for the appointment of the guardian, a copy of which is attached. 13. There are no persons interested in this proceeding other than those mentioned above. 14. No prior application has been made to any court, including a Native- American tribunal, for the relief requested herein (except [specify]: WHEREFORE, I am requesting that an order be entered appointing [specify]: to be the ”guardian of my person ”permanent guardian until I reach the age of: ”18 ” 21 and that letters of guardianship issue. Dated: Signature of Petitioner American LegalNet, Inc. www.FormsWorkflow.com Form 6-1-a Page 6 Print or type name Signature of Attorney, if any Attorney’s Name (Print or Type) Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK COUNTY OF ) )ss.: ) ,being duly sworn, says that (s)he is the Petitioner in the above-named proceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. Sworn to before me this day of . Petitioner (Deputy)Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkflow.com