Sect. 756, 771, 772 F.C.A. FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF_________ _______________________________________________ In the Matter of A Person Alleged to be a Person in Need of Supervision, Respondent. _______________________________________________ TO THE FAMILY COURT: Form 7-11 (Person in Need of Supervision) 7/83 Docket No.___________ PETITION (Discontinuance of Treatment) The undersigned Petitioner respectfully alleges (upon information and belief) that: 1. Petitioner,______________________________________________, is an authorized agency with which the above-named respondent has been placed by Order of this Court dated __________________, _____, pursuant to section 756 of the Family Court Act. 2. Petitioner (has discontinued or suspended its work in that: [state facts] ) (is unwilling to care for the above-named respondent for the reason that support by (the State of New York) (__________________, one of its political subdivisions) has been discontinued in that: [state facts] ) (has fundamentally altered its program and as a result the above-named respondent can no longer benefit from it, in that: [state facts] ). American LegalNet, Inc. www.USCourtForms.com Form 7-11 page 2 3. No previous application has been made to any court or judge for the relief requested herein(except________________________________________________.) 5. Your Petitioner has made application to the agency with which the child has been placed for the release of Respondent, which application was (denied) (not granted within thirty days from the day application was made) WHEREFORE, Petitioner prays that an Order be made herein and entered returning respondent to this Court for such further or other disposition as to the Court may seem just and proper. Dated:________________, ___________. _________________________________ Petitioner (By:______________________________ Name __________________________________ Title) American LegalNet, Inc. www.USCourtForms.com Form 7-11 page 3 VERIFICATION (Agency) STATE OF NEW YORK ) ) ss.: COUNTY OF_______________________ ) _________________________________________, being duly sworn, deposes and says: That (s)he is the______________________________ of ____________________, an agency authorized to originate the above- entitled proceeding, and is acquainted with the facts and circumstances therein; that (s)he has read the foregoing 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 as to those matters (s)he believes it to be true. _____________________________ Name _____________________________ Title Sworn to before me this_____ day of _________________, _____ . ________________________________________ Notary Public American LegalNet, Inc. www.USCourtForms.com