S.S.L. § 383-c, 384, 384-c FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF Form SURR-1 (Surrender­ Notice of Proceeding for Approval of Judicial or Extra-judicial Surrender Instrument) (9/2006) Docket No. NOTICE OF PROCEEDING FOR APPROVAL OF 9 JUDICIAL 9 EXTRA-JUDICIAL SURRENDER INSTRUMENT In the Matter of the Application for Approval of a Surrender Instrument Pursuant to Sections 383-c or 384 of the Social Services Law Concerning CIN# Child's Name: Date of Birth: TO: PLEASE TAKE NOTICE that the annexed petition requesting approval of an instrument of surrender concerning the above-named child has been presented to the Family Court of the State of New York, County, located at [specify address]: and that a hearing on the petition will be held on [specify date and time]: at which time you will have an opportunity to be heard. PLEASE TAKE FURTHER NOTICE that you have the right to be represented by a lawyer and, if you are a custodial or non-custodial parent, guardian, grandparent, foster parent or other person having physical or legal custody of the above-named child and the Court finds that you are unable to pay for a lawyer, you have the right to have a lawyer assigned by the Court. FAILURE TO APPEAR MAY RESULT, WITHOUT FURTHER NOTICE, IN COURT APPROVAL OF THE SURRENDER INSTRUMENT AND TRANSFER OF CUSTODY AND GUARDIANSHIP OF THE CHILD TO A SOCIAL SERVICES OFFICIAL OR AUTHORIZED AGENCY FOR THE PURPOSE OF ADOPTION. NOTICE TO ADJUDICATED, ACKNOWLEDGED OR IDENTIFIED FATHERS, pursuant to Social Services Law §384-c:1 You have a right to appear to present evidence to the Family Court relevant to the best interests of the child. Your failure to appear will be considered a denial of your interest in the child and may result, without further notice, in court approval of the surrender instrument and transfer of custody and guardianship of the child to a social services official or authorized agency for the purposes of adoption. Dated: ___________________________________ Name of Attorney(s) ___________________________________ Attorney(s) for Petitioner: ___________________________________ Mailing Address ____________________________________ Telephone Number This notice paragraph applies to you IF you have: (i) been adjudicated the father by a court in New York State; (ii) been adjudicated the father elsewhere by a court order that has been filed with the national putative father registry; (iii) filed a timely notice of intent to claim paternity and have not revoked it; (iv) been identified as the father in the child's birth certificate or in a sworn written statement by the child's mother; (v) been openly living with the child's mother as the child's parent when the court proceeding was begun or the child was placed with the authorized agency; (vi) been married to the child's mother within six months after the child's birth and before execution of the surrender instrument; or (vii) filed an acknowledgment of paternity with the national putative father registry. American LegalNet, Inc. www.FormsWorkflow.com 1