Soc. Serv. Law §§ 383-c, 384 Form SURR-6 (Surrender­ Order Approving or Disapproving Extra-judicial Surrender Instrument) (8/2010) At a term of the Family Court of the State of New York, held in and for the County of , at New York, on , . P R E S E N T: Hon. Judge _____________________________________ In the Matter of the Application for Approval of an Extra-judicial Surrender Instrument Concerning Child's Name: Date of Birth: Docket No. CIN # Pursuant to Section 383-c 384 of the Social Services Law ____________________________________________ ORDER APPROVING DISAPPROVING EXTRA-JUDICIAL SURRENDER INSTRUMENT THE NEXT PERMANENCY HEARING SHALL BE HELD ON [specify date/time]:1: The petition of [specify]: , an authorized agency, dated [specify]: , having been filed requesting Court approval of an extra-judicial instrument of surrender executed on [specify date]: , by [specify person executing surrender]: committing the guardianship of the person and custody of [specify child's name]: , a child under the age of eighteen years to [specify agency]: , an authorized agency; And the person executing the surrender having been duly served with notice of this proceeding and having [check applicable box(es)]: personally appeared not appeared before this Court, and counsel for the person who executed the surrender having personally appeared not If the surrender is approved, a permanency hearing must be scheduled for a date certain not later than 30 days after the earlier of this Order or the Court's oral ruling. If it is denied, but the child remains in foster care, the permanency hearing shall be held, in most cases o n the previously-scheduled date certain, not later than eight months from removal of the child from home or no more than six months from the most recent permanency hearing. If the child is finally discharged from foster care, the previously-scheduled hearing date shall be cancelled. If the child's placement has been continued and the child has a sibling or half- sibling removed from the home, whose permanency hearing is scheduled before this Court, the date certain shall be the same as the date certain for the sibling's or half-sibling's permanency hearing, unless the sibling or half-sibling was removed on a juvenile delinquency or PINS petition or unless he or she has been freed for adoption. 1 American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-6 appeared before this Court; And a attorney for the child having been appointed to represent the child and having personally appeared not appeared before this Court; Page 2 And the following persons having been given notice pursuant to Section 384-c of the Social Services Law [specify, including relationship to child and whether they appeared or not]: [Required in cases involving Native-American children; check if applicable ]: And the following having been duly notified [check applicable box(es)]: parent/custodian (unless parental rights have been terminated) tribe/nation United States Secretary of the Interior; And the tribe/nation having: appeared and participated as a party; appeared and declined to assume jurisdiction; appeared and requested transfer of jurisdiction; not appeared; And this Court having determined by satisfactory proof that there are no additional persons who are entitled to notice pursuant to Social Services Law §384-c; And the following person(s) having intervened as (an) interested party (parties): Name Relationship prospective adoptive parent prospective adoptive parent custodian in excess of 12 months custodian in excess of 12 months other [specify]: 2 [Required finding where surrender is subject to condition of adoption by specific individual; check box if applicable]: And the surrender having been conditioned upon adoption by [specify]: who, in accordance with regulations of the NYS Office of Children and Family Services, has been [check applicable box(es)]: investigated and approved as a prospective adoptive parent certified or approved as a foster parent [Required finding where post-adoption contact agreement has been submitted for approval; check box if applicable]: And the annexed post-adoption contact agreement having been determined to be: in the child's best interests not in the child's best interests; [Required findings where surrender is of a child in foster care pursuant to Social Services Law §383-c; check boxes if applicable]: And affidavits of at least two witnesses to the execution of the surrender instrument, at , 2 Intervenors may proceed in their true names or anonymously. See S.S.L. §§383-c(9), 384(3). American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-6 Page 3 least one of whom was an employee of the authorized agency and one of whom was a certified social worker or attorney independent of the authorized agency, having been filed with the petition in accordance with Section 383-c(4)(b) of the Social Services Law; And an affidavit of an authorized agency employee responsible for arranging supportive counseling for persons executing surrender instruments having been filed with the petition in accordance with Section 383-c(4)(c) of the Social Services Law; And an affidavit from the provider of supportive counseling having been filed with the petition in accordance with Section 383-c(4)(c) of the Social Services Law And the person executing the surrender instrument having been provided with a copy of the surrender which was read in full in his or her principal language, and such person having been 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; And the person executing the surrender instrument having been 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 he or she may receive notices regarding any substantial failure of a material condition, unless this notification is expressly waived by a statement written by such person and appended to or included in the surrender, which notification was was not waived in this case; [Required finding where an extra-judicial surrender of a child not in foster care, pursuant to Social Services Law §384, is approved; check box if applicable]: And the person executing the surrender instrument having acknowledged in wri