Soc Serv. Law §§ 384-b, 384-c Form TPR-10 (Petition- Termination of Parental Rights – Severe or Repeated Child Abuse) (8/2010) 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 CIN # A Child under the Age of Eighteen Years, alleged to be a □Severely □Repeatedly Abused Child Docket No. PETITION □ SEVERE □ REPEATED CHILD ABUSE 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 are: Name Last-Known Address American LegalNet, Inc. www.FormsWorkFlow.com TPR-10 page 2 4. a. The name and last-known address of any other interested party who should be afforded notice of this proceeding are: Name 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 was removed from his or her home on [specify]: and 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]: 6. a. (Upon information and belief, the authorized agency has made diligent efforts to encourage and strengthen the parental relationship as follows) [specify efforts]: b. (Upon information and belief the authorized agency has not made diligent efforts to encourage and strengthen the parental relationship because of a judicial order that reasonable efforts are not required) [specify court, county, docket number and date of such finding]: . 7. (Upon information and belief) (T(t)he Respondent(s), (has)(have) severely abused the above-named child, in that [specify]: □ father □ mother 8. (Upon information and belief) (T)(t)he Respondent(s), (has)(have) repeatedly abused the above-named child, in that [specify]: □ father □ mother 9. (Upon information and belief, the following prior □ convictions □ child abuse findings support the allegations in this case: [Specify criminal conviction(s) or child abuse finding(s), including court, county, date and, in the case of child abuse findings, whether the finding was made upon clear and convincing evidence or a preponderance of the evidence]: 10. The best interests of the child will be promoted by commitment of the guardianship and custody of the child to: ❑ an authorized agency ❑ foster parent(s) for the following reasons: [If appropriate, include facts regarding a non-respondent parent.] American LegalNet, Inc. www.FormsWorkFlow.com TPR-10 page 3 11. 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 TPR-12]. 12. (except No previous application has been made to any court or judge for the relief sought herein WHEREFORE, Petitioner requests an order determining that the above-named child is a □ severely and □repeatedly abused child, and committing the guardianship and custody of the child to [specify]: □ an authorized agency □ foster parent(s), and for such other and further relief as in the best interests of the child may be granted. Dated: . □ Agency by: Name: Title: □ Foster parent Print or type name 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, ; 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 American LegalNet, Inc. www.FormsWorkFlow.com TPR-10 page 4 VERIFICATION (Individual) STATE OF NEW YORK COUNTY OF ) )SS.: ) , 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. Petitioner Sworn to before me this day of . (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkFlow.com