F.C.A. §§ 712, 732, 733, 736 Form 7-4 (Person in Need of Supervision­Petition) 9/2012 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: Docket No. PETITION The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner, , resides at . 2. Petitioner is a person authorized to institute a proceeding under Article 7 of the Family Court Act by reason of the fact that (s)he is [specify relationship to Respondent]: 3. The Respondent above-named is a [check applicable box]: Gmale Gfemale who was born on [specify]: . 4. The Respondent [check applicable box]: G is G is not a Native American child 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 [where tribe/nation undetermined; give notification date]: 5. a. The following are the names and addresses, unless ordered confidential pursuant to Family Court Act §154-b, of the parent(s) or other person(s) legally responsible for the care of Respondent or with whom Respondent resides: Name Residence Relationship b. The following are the names and addresses, unless ordered confidential pursuant to Family Court Act §154-b, of Respondent's non-custodial parent(s), if any: Name Residence Relationship 6. Respondent [check applicable boxes]: G does not attend school in accord with the provisions of part one of Article 65 of the Education Law American LegalNet, Inc. www.FormsWorkFlow.com Form 7-4 Page 2 G is incorrigible, ungovernable or habitually disobedient and beyond the lawful control of parent or other lawful authority G violates the provisions of section 221.05 of the Penal Law in that (s)he: [Set forth in a concise statement of the acts of which the foregoing allegations are based and the time and place they allegedly occurred]: 7. [Applicable in cases where habitual truancy is alleged and/or where petitioner is an official of a school district or local education agency]: The school district or local education agency has taken the following steps to improve the Respondents's school attendance and/or behavior prior to the date of this petition: 8. Respondent was under eighteen years of age at the time of foregoing acts and is now under eighteen years of age. 9. Petitioner has complied with the requirements of Family Court Act §735. [Attach notice from designated diversion services agency]. 10. Respondent requires supervision or treatment. 11. As to the allegations herein made upon information and belief, the sources of Petitioners' information and grounds of belief are [check applicable boxes]: G the statements and admissions of Respondent G the statements and depositions of witnesses now on file with this Court G other [specify]: WHEREFORE, Petitioner requests that the Respondent be adjudged a person in need of supervision and dealt with in accordance with the provisions of Article 7 of the Family Court Act. Dated: , ___________________________________ Petitioner ___________________________________ Petitioner ___________________________________ Print or type name ___________________________________ Signature of Attorney, if any ___________________________________ Attorney's Name (Print or Type) ___________________________________ ___________________________________ ___________________________________ Attorney's Address and Telephone Number NOTICE: [APPLICABLE WHERE PETITIONER IS THE PARENT OR OTHER PERSON LEGALLY RESPONSIBLE FOR THE RESPONDENT CHILD]: UPON PLACEMENT OF THE RESPONDENT CHILD WITH THE DEPARTMENT OF SOCIAL American LegalNet, Inc. www.FormsWorkFlow.com Form 7-4 Page 3 SERVICES OR ANY OTHER AGENCY, THE PETITIONER MAY BE NAMED AS THE RESPONDENT IN A CHILD SUPPORT PETITION BROUGHT PURSUANT TO ARTICLE 4 OF THE FAMILY COURT ACT AND MAY BE LIABLE FOR THE SUPPORT OF THE CHILD. VERIFICATION (Individual) STATE OF NEW YORK COUNTY OF ) ) ) ss.: _______________________________, being duly sworn, deposes and says: That (s)he is the in the above-entitled proceeding and is acquainted with the facts and circumstances thereof; 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. __________________________ Petitioner Sworn to before me this day of , __________________________ (Deputy) (Clerk of the Court) (Notary Public) VERIFICATION (Agency) STATE OF NEW YORK COUNTY OF ) )ss.: ) _______________________________, 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.FormsWorkFlow.com