Form SURR-5 (Extra- Judicial Surrender of Child in Foster Care-Affidavit of Authorized Agency Employee Responsible for Arranging Supportive Counseling)1 (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Application for Docket No. Approval of a Surrender Instrument Concerning AFFIDAVIT OF AUTHORIZED AGENCY EMPLOYEE RESPONSIBLE FOR ARRANGING SUPPORTIVE COUNSELING ­ EXTRA-JUDICIAL SURRENDER OF CHILD IN FOSTER CARE CIN # Pursuant to Section 383-c of the Social Services Law ..................................................................................... STATE OF NEW YORK ) )ss.: COUNTY OF ) I , [specify name of witness]: following: , having been duly sworn, deposes and states the Soc. Serv. Law § 383-c(4)(c) 1. I am an employee of the following authorized agency [specify]: and am responsible for arranging supportive counseling for parents or guardians who execute extra-judicial surrenders of children in foster care. 2. On [specify date]: executing surrender]: as follows [specify]: 3. On [specify date]: 9 accepted 9 did not accept , I arranged for supportive counseling for [specify person to be provided by [specify]: , [specify person executing surrender]: the offer of supportive counseling. 4. [Check applicable box or delete inapplicable provision]: Upon information and belief, 9 Supportive counseling was provided to the person executing the surrender as follows [specify date, provider and nature of supportive counseling]: 9 Supportive counseling was not provided to the person executing the surrender. _________________________________________________ Signature of Authorized Agency Employee Sworn to before me this day of , ________________________________ Notary Public (Deputy) Clerk of Court If the employee-witness to the surrender was the employee who arranged for supportive counseling, Form SURR-4 may be utilized. American LegalNet, Inc. www.FormsWorkflow.com 1