F.C.A.§1091 Form PH-7c (Affidavit in Support of Order to Show Cause by Agency to Return Youth to Foster Care) 8/2010 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ....................................................................................... In the Matter of Docket No. AFFIDAVIT IN SUPPORT OF ORDER TO SHOW CAUSE BY AGENCY TO RETURN YOUTH TO FOSTER CARE CIN # A Child under 21 Years of Age Who Was Discharged From Foster Care ....................................................................................... STATE OF NEW YORK ) )ss.: COUNTY OF NEW YORK ) I, [name]: , swear the following to be true under the penalties of perjury: 1. I am [state title/position and agency]: and am making this affidavit in support of an Order to Show Cause for an order for the above-named former foster youth to return to foster care. 2. The above-named youth, who was born on [specify date of birth]: was discharged from foster care on [specify date]: At that time, the youth was 18 years of age or older and did not consent to remain in foster care. 3. The above-named youth has consented to return to foster care and has no reasonable alternative to foster care because [specify, including any relevant facts and circumstances]: 4. [Check applicable box]: □ The youth has consented to enroll in and attend an appropriate educational or vocational program and has agreed to cooperate with referrals made to assist in enrolling in such a program. OR □ It would be unnecessary or inappropriate for the youth to attend an educational or vocational program because [specify]: 5. Continuation of the above-named youth’s final discharge from foster care would be contrary to his or her best interests and return of the youth to foster care is compelled by the following reason(s) [specify]: This assertion is based upon the following information [check applicable box(es)]: □ Permanency report, sworn to on [specify date]: American LegalNet, Inc. www.FormsWorkFlow.com Form PH-7c ❑ Case record, dated [specify]: ❑ The report of [specify]: ❑ Testimony of [specify]: ❑ Other [specify]: Page 2 , dated: , on [specify date]: 6. Reasonable efforts, where appropriate, to prevent or eliminate the need for the abovenamed youth to return to foster care [check applicable box and state reasons as indicated]: □ were made as follows [specify]: □ were not made, (because [specify reason if efforts would have been inappropriate]: ). This assertion is based upon the following information [check applicable box(es)]: □ Permanency report, sworn to on [specify date]: ❑ Case record, dated [specify]: ❑ The report of [specify]: , dated: ❑ Testimony of [specify]: , on [specify date]: ❑ Other [specify]: 7. [Check box if applicable]: □ This Court should enter an order immediately returning the above-named youth to foster care pending a decision on this motion because [specify reason(s)]: 8. No previous application has been made to any court or judge for the relief herein requested [check box if applicable]: □ except [specify, including any prior motions to return to foster care]: WHEREFORE, I respectfully request that this Court issue an Order returning the above-named youth to foster care and for such other and further relief as it may deem proper. Dated , . ______________________________________ Signature of Agency Official or Caseworker ______________________________________ Print or Type Name Sworn to before me this day of , (Deputy) Clerk of the Court Notary Public _____________________________________ Signature of Attorney, if any ______________________________________ Attorney’s Name (print or type) ______________________________________ ______________________________________ ______________________________________ Attorney’s Address and Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com