Soc. Serv. Law §§ 383-c, 384; Family Court Act §1055-a Form SURR-7 (Conditional Surrender­ Petition for Review of Substantial Failure of Material Condition or Violation of Post -Adoption Contact Agreement Prior to Adoption Finalization) (8/2010) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of a Conditional Surrender Instrument Concerning Child's Name: Date of Birth: CIN # Pursuant to Section 383-c 384 of the Social Services Law ........................................................................................ TO THE FAMILY COURT OF THE COUNTY OF Docket No. PETITION FOR REVIEW OF SUBSTANTIAL FAILURE OF MATERIAL CONDITION IN CONDITIONAL SURRENDER OR VIOLATION OF POST-ADOPTION CONTACT AGREEMENT (Prior to Adoption Finalization) : The undersigned Petitioner respectfully alleges upon information and belief that: 1. Petitioner, [specify]: , is [check applicable box]: an authorized agency having its office and place of business at [specify]: in the County of [specify]: , State of New York; the person who executed a conditional surrender of the above-named child; the attorney for the above-named child. 2. a. On [specify date]: , this Court approved a [specify]: judicial extra-judicial surrender of the above-named child, that contained the following condition(s) [specify]: b. [Applicable where violation of Post-adoption Contact Agreement is alleged; attach copy of agreement]: On [specify date]: , this Court approved a Post-adoption Contact Agreement and incorporated it into the Order Approving the Surrender. The child has not yet been adopted; the status of the adoption of the child is as follows [specify]: 3. a. The person executing the surrender [specify]: did did not sign a written statement waiving notification of any failure of a material condition. b. [Applicable where notification of failure of material condition was not waived]: The person executing the surrender did did not provide the authorized agency with an address for notifications, as well as any changes of address, if any. failure of a material condition of the surrender, violation of the Post Adoption Contact Agreement, as follows [specify facts and circumstances, including dates]: 4. There has been a 5. [Check applicable box(es)]: a. The authorized agency notified the person who executed the surrender on [specify date]: American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-7 Page 2 regarding the above failure of the condition violation of the Post-adoption Contact Agreement. The authorized agency did not notify the person who executed the surrender of the above failure of the condition violation of the post-adoption contact agreement b. The authorized agency notified the child's attorney for the child on [specify date]: regarding the above failure of the condition violation of the Post-adoption Contact Agreement. The authorized agency did not notify the child's attorney for the child of the above failure of the condition violation of the post-adoption contact agreement. 6. a. The child is in the custody of [specify]: unless confidential]: and resides with [specify, b. The most recent permanency hearing regarding the child was held in [check applicable box]: this Court another Court [specify]: on [specify date]: The next permanency hearing is scheduled for the following date certain [specify]: 7. No previous application has been made for the review of the failure of the above-named material condition in this instrument of surrender or violation of the Post-adoption Contact Agreement to any court or judge, except [specify; delete if inapplicable]: . WHEREFORE, Petitioner requests that this Court enter an order providing for the following relief [specify]: and for such other and further relief as this Court may deem just and proper. Petitioner Print or type name Signature of Attorney, if any Attorney's Name (Print or Type) Attorney's Address and Telephone # VERIFICATION ) )SS.: COUNTY OF ) ,being duly sworn, deposes and says: That (s)he is and is acquainted with the facts and circumstances of the above-entitled proceeding; that (s)he has read the foregoing petition and knows the contents thereof; that the same is true to (his)(her) own knowledge except as to those matters therein stated to be alleged upon information and belief, and that as to those matters (s)he believes it to be true. STATE OF NEW YORK Petitioner Sworn to before me this day of , . (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkFlow.com