Soc. Serv. Law §§ 383-c(4) Form SURR-4-a (Affidavit of Independent Witness to Execution of Extra- Judicial Surrender of Child in Foster Care ­ Non-agency Employee) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Application for Approval of a Surrender Instrument Concerning CIN # Pursuant to Section 383-c of the Social Services Law ........................................................................................ STATE OF NEW YORK )ss.: COUNTY OF I , [specify name of witness]: following: ) ) Docket No. AFFIDAVIT OF INDEPENDENT WITNESS TO EXECUTION OF EXTRA-JUDICIAL SURRENDER OF CHILD IN FOSTER CARE , having been duly sworn, deposes and states the 1. [Check all applicable box(es)]:1 Q I am an attorney at law duly licensed to practice under the laws of the State of New York and have an office at [specify address]: Q I am a certified social worker duly licensed to practice under the laws of the State of New York and have an office at [specify address]: Q I am [specify relationship, if any, to person executing surrender and/or child]: I Q reside Q have an office at [specify residential or office address]: 2. On [specify date]: , I witnessed the execution and acknowledgment of the surrender of the above-named child by [specify]: at the following location [specify]: 3. I am not an employee, volunteer, consultant or agent of, or attorney for, the authorized agency to which the child is being surrendered and I do not serve as the sole non-employee witness for the agency. I am not an employee of an agency or organization contractually or financially responsible for or involved with the delivery of services to the above-named child or his or her family, nor am I related within the second degree to any employee-witness to the surrender of the child. Neither I nor my At least one witness must be an attorney or certified social worker who is independent of, and not employed by, the authorized agency to whom the child was surrendered. See Soc. Ser. Law §383-c(4)(a). American LegalNet, Inc. www.FormsWorkflow.com 1 Form SURR-4-a Page 2 employer have received any payment or compensation other than actual and reasonable transportation expenses, if any, incurred in order to witness the surrender. 2 4. The person executing the surrender instrument was provided with a copy of the surrender and the surrender was read in full in his or her principal language of [specify]: . The person executing the surrender instrument was given an opportunity to ask questions and obtain answers regarding the nature and consequences of the surrender, including the consequences of, and procedures to be followed in, cases of a substantial failure of a material condition, if any, contained in the surrender instrument. The person executing the surrender instrument was informed of the obligation to provide the authorized agency with a designated mailing address, as well as any subsequent changes in such address, at which the person executing the surrender may receive notices regarding any substantial failure of a material condition, unless this notification is expressly waived by a statement written by the person executing the surrender instrument and appended to or included in the surrender instrument. ____________________________________________________________ Signature of Independent Witness to Execution of Extra-judicial Surrender Sworn to before me this day of , ________________________________ Notary Public (Deputy) Clerk of Court 2 See 18 NYCRR §421.6(e). American LegalNet, Inc. www.FormsWorkflow.com