Soc. Serv. Law §§ 383-c, 384; Family Court Act §1055-a Form SURR-8 (Conditional Surrender­ Order Determining Petition for Review of Substantial Failure of Material Condition or Violation of Post -Adoption Contact Agreement Prior to Adoption Finalization) (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 a Conditional Surrender Instrument Concerning Child's Name: Date of Birth: CIN # Docket No. ORDER DETERMINING PETITION FOR REVIEW OF SUBSTANTIAL FAILURE OF MATERIAL CONDITION IN CONDITIONAL SURRENDER OR VIOLATION OF POST-ADOPTION CONTACT AGREEMENT (Prior to Adoption Finalization) Pursuant to Section 383-c 384 of the Social Services Law ____________________________________________ The petition of [specify]: , dated [specify]: , having been filed requesting Court review of the [check applicable box(es)]: failure of a substantial material condition in a judicial extra-judicial instrument of surrender, approved by this Court on [specify date]: which committed the guardianship of the person and custody of [specify child's name]: a child under the age of 18 years to [specify agency]: , an authorized agency; violation of a Post-adoption Contact Agreement, approved by this Court on [specify date]: and incorporated into the Order Approving the Surrender; [Required where Petitioner is the authorized agency or attorney for the child]: And the person executing the surrender having [check applicable box(es)]: been duly served with notice of this proceeding and having personally appeared not appeared before this Court, and counsel for the person who executed the surrender having personally appeared not appeared before this Court; waived notification of any substantial failure of a material condition; [Required where substantial failure of material condition is alleged and Petitioner is the American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-8 authorized agency]: And the petition having been filed not having been filed within 30 days of the substantial failure of a material condition, but the Petitioner having shown not shown good cause; Page 2 [Required where substantial failure of material condition is alleged and Petitioner is the person who executed the surrender or attorney for the child]: And the petition having been filed not having been filed within 60 days of receipt of notification of the substantial failure of a material condition; And the authorized agency having guardianship and custody of the child having [check applicable box(es)] been duly served not been duly served with notice of this proceeding and having: appeared not appeared before this Court, and counsel for the authorized agency having appeared not appeared before this Court; [Required where Petitioner is the authorized agency or person who executed the surrender]: And the attorney for the child for the child having been duly served with notice of this proceeding and having: personally appeared not appeared before this Court; And the following person(s) having intervened as (an) interested party (parties) [specify, including relationship to child; note that intervenors may proceed in their true names or anonymously. See S.S.L. §§383-c(9), 384(3)]: And the matter having duly come on for a hearing before this Court, and the Court, after hearing the proof and testimony offered in relation to the case, having determined that [check applicable box]: there has been a [check applicable box]: substantial failure of a material condition in the conditional surrender violation of the Post-adoption Contact Agreement, as follows [specify]: there has been no [check applicable box]: substantial failure of a material condition in the conditional surrender violation of the Post-adoption Contact Agreement; NOW THEREFORE, it is ORDERED that [specify]: ORDERED that [specify]: ENTER _____________________________________ Judge of the Family Court Dated: American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-8 PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. Page 3 Check applicable box: Order mailed on [specify date(s) and to whom mailed ]:___________________________ Order received in court on [specify date(s) and to whom given]:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com