F.C.A. §764 Form 7-9 (Person in Need of Supervision) 8/2002 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF_____ _____________________________________________ In the Matter of Docket No.___________ A Person Alleged to be a Person in Need of Supervision, Respondent. ____________________________________________ TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner,______________________________________________, is the Gparent Gguardian Gnext friend of the above-named Respondent, and resides at [specify]: OR Petitioner, that has its principal office at [specify]: , is a duly authorized agency PETITION (Termination of Placement) 2. Under an Order of Fact-finding and Disposition of this Court, dated________________________, the Respondent was adjudicated to be a person in need of supervision within the meaning of Article 7 of the Family Court Act and placed in the custody of __________________________________________________________________ for a period of _____ months, terminating on ___________________________. 3. Respondent is now in the custody of [specify]: placement should be terminated for the following reasons: 4. No previous application has been made to any court or judge for (except [specify]: ________________________________________________.) and the this relief 5. The Petitioner has made application to the agency with which the child has been placed for the release of Respondent, which application was [check applicable box]: Gdenied Gnot granted within thirty days from the day application was made) WHEREFORE, Petitioner requests this Court to issue an Order terminating the placement of Respondent and directing release. Dated:________________, ___________. ______________________________ Petitioner American LegalNet, Inc. www.USCourtForms.com Form 7-9 Page 2 By: ______________________________ Name __________________________________ Title Signature of Attorney, if any Attorney's Address and Telephone Number VERIFICATION (Individual) ) ) ss.: COUNTY OF_____________________ ) _____________________________________________, being duly sworn, deposes and says: That (s)he is the__________________________________________________ in 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. _____________________________ Sworn to before me this _____ day of _____________, _____ . STATE OF NEW YORK (Deputy) (Clerk of the Court) (Notary Public) VERIFICATION (Agency) ) ) 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 STATE OF NEW YORK