Soc. Serv. Law §§ 383-c(3)(b), 383-c(4)(d); 384-c(2) ; Family Court Rule 205.48 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Application for “ Execution of a Judicial Surrender Instrument “ Approval of an Extra-judicial Surrender Instrument Concerning Form SURR-1-a (Affidavit of Caseworker Regarding Persons Entitled to Notice of Surrender of Child in Foster Care) 9/2007 Docket No. AFFIDAVIT OF CASEWORKER REGARDING PERSONS ENTITLED TO NOTICE OF 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 caseworker]: the following: , having been duly sworn, depose and state 1. I am an employee of the following authorized agency [specify]: and have been the caseworker for [specify]: since [specify date]: I am submitting this affidavit to set forth information regarding any persons entitled to notice of the surrender of the above-named child, pursuant to Social Services Law §384-c(2), including any putative father whose consent to adopt is required by section 111 of the Domestic Relations Law or who is entitled to notice of an adoption pursuant to section 111-a of the Domestic Relations Law. 2. The child [specify]: was born on [specify date]: and was removed into the custody of [specify]: on [specify date]: The child has remained in foster care since “ the removal date “ other [specify date]: 3. a. The Respondent [specify]: , the mother of the child [check applicable box]: “ is seeking approval of an extra-judicial surrender executed on [specify date]: OR “ seeks to execute a judicial surrender before this Court. b. The Respondent mother [check applicable box(es)]: “ has provided information in a sworn, written statement naming [specify]: as the father of the child. A copy of that statement has been filed with the Court. “ has provided the following information regarding the child’s father, although not in a sworn, written statement [specify]: American LegalNet, Inc. www.FormsWorkflow.com Form SURR-1-a Page 2 “ has not provided information regarding the child’s father. 4. The following person(s) are entitled to notice of the surrender, pursuant to SSL §384-c(2): Name Address Reason for Notice Source of Information 5. Other than the person(s), if any, named in Paragraphs 3(b) and 4, above, there is no person: “ adjudicated by a court in this state to be the father of the child; “ adjudicated by a court of another state or territory of the United States to be the father of the child as evidenced by a certified copy of the court order filed with the putative father registry, pursuant to SSL § 372-c; “ who has timely filed an unrevoked notice of intent to claim paternity of the child, pursuant to SSL § 372-c; “ who is recorded on the child's birth certificate as the child's father; “ who openly lived with the child and the child's mother at the time the proceeding was initiated or at the time the child was placed in foster care, and who is holding himself out to be the child's father; “ who has been identified as the child's father by the mother in written, sworn statement, other than as referred to above; “ who was married to the child's mother within six months subsequent to the birth of the child and prior to the initiation of this proceeding; or “ who filed with the putative father registry an instrument acknowledging paternity of the child, pursuant to section 4-1.2 of the Estates, Powers and Trusts Law. The source(s) of my information are as follows [specify]: _________________________________________________ Signature of Caseworker _________________________________________________ Title and Agency Sworn to before me this day of , ________________________________ Notary Public (Deputy) Clerk of Court American LegalNet, Inc. www.FormsWorkflow.com