DRL Art. 5-A Form UCCJEA-1 (Petition-Custody, Visitation–UCCJEA) 3/2009 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ..................................................................................... In The Matter of a Proceeding for Custody Visitation under the Uniform Custody Jurisdiction and Enforcement Act Docket No. Petitioner PETITION–UCCJEA CUSTODY VISITATION -againstRespondent ....................................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges upon information and belief that: 1. a. I am [specify relationship to child; if foster parent, agency, institution or other relationship, so state]: and am seeking an order of [check applicable box(es)]: custody visitation regarding [specify child’s name]: b. I [check applicable box]: reside am located at [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]: c. [Applicable when Petitioner is on active military duty or has recently returned from active military service; DELETE if inapplicable]: “ Petitioner is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]:1 “ Petitioner returned from active duty, deployment or temporarily assignment to military service as follows [specify date of return, type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]: 2. a. Respondent [specify name]: agency, institution or other relationship, so state]: is [specify relationship to child; if foster parent, b. Respondent [check applicable box]: resides is located at [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]: 1 Inapplicable if Petitioner is based at a permanent duty station or has had a permanent reassignment of station. American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-1 Page 2 c. [Applicable when Respondent is on active military duty or has recently returned from active military service; DELETE if inapplicable]: “ Respondent is on active duty, deployed or temporarily assigned to military service as follows [specify type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]:2 “ Respondent returned from active duty, deployment or temporarily assignment to military service as follows [specify date of return, type of service, military branch or National Guard unit, anticipated dates and location of duty and how duty is likely to affect custody or visitation, if at all]: 3. The name, present address and date of birth of each child who is the subject of this proceeding are as follows [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254] : Name Address Date of Birth 4. This Court has jurisdiction to issue a child custody or visitation order pursuant to Section 76(1) of the Domestic Relations Law on the following ground(s) [check all applicable box(es)]: a. this state is the home state of the child on the date of the filing of this petition; this state was the home state of the child within six months before the filing of this petition; and the child is absent from this state but the following parent or person acting as a parent continues to live in this state [specify]: ; OR b. the child and the child’ s parents, or the child and at least one parent or a person acting as a parent, have a significant connection with this state other than mere physical presence; and substantial evidence is available in this state concerning the child’ s care, protection, training, and personal relationships; and EITHER [check applicable box]: a court of another state does not have home state jurisdiction under paragraph (a); OR a court of the home state of the child [check applicable box]: has declined should decline to exercise jurisdiction on the ground that this state is the more appropriate forum under Domestic Relations Law §§76-f or 76-g, because [specify]: c. d. OR all courts having jurisdiction under paragraph (a) or (b) of this subdivision [check applicable box]: have declined “ should decline to exercise jurisdiction on the ground that a court of this state is the more appropriate forum to determine the custody of the child under Domestic Relations Law §§76-f or 76-g, because [specify]: OR no court of any other state would have jurisdiction under the criteria specified in paragraph (a), (b) or (c). 2 Inapplicable if Respondent is based at a permanent duty station or has had a permanent reassignment of station. American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-1 Page 3 5. This Court should exercise temporary, emergency jurisdiction, pursuant to Domestic Relations Law §76-c, because the child is presently in this State and [check one or both boxes]: the child has been abandoned [specify facts or circumstances]: it is necessary in an emergency to protect the child, a sibling or parent of the child [specify facts or circumstances]: 6. [Delete if inapplicable]: An order was issued by Court, County, State of , referring the issue of custody visitation to the Family Court of the State of New York in and for the County of [specify]: 7. Check applicable box(es): No proceeding has been commenced that could affect this action. The following proceeding(s) have been commenced that could affect this action, [specify jurisdiction, court, docket or index number, type and status of proceeding]: (Upon information and belief) an order of custody visitation of one or more of the same child(ren) has been registered in New York State another state, territory, tribal jurisdiction or country [specify court(s) and jurisdiction(s) in which order registered, date of registration(s), court and jurisdiction that issued the order, children covered by the order and date of order, if available]: 8. [Check applicable box(es). Delete inapplicable provisions]: a. The father of the child(ren) who (is)(are) the subject(s) of this proceeding is [specify]: . The father was married to the child(ren)’s mother at the time of the conception or birth. An order of filiation was made on [specify date and court and attach true copy]: An acknowledgment of paternity was signed on [specify date]: by [specify who signed and attach a true copy]: The father is deceased. b. The father of the child(ren) who (is)(are) the subject(s) of this proceeding has not been legally established. c. A paternity agreement or compromise was approved by the Family Court of County on , , concerning [name parties to agreement or compromise and child(ren) and attach a true copy]: 9. [Applicable to cases in which mother is not a party]: The name and address of the mother is [indicate if deceased or if address ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §§76-h(5), 254]: 10. The name and present address of the person(s) with whom each child resided during the past five years are as follows [indicate if address was ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]: Name Address Duration Name of Person Current Address of American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-1 Page 4 (from/to) With Whom Child Resided the Person With Whom Child Resided 11. Petitioner has has not participated as a party witness other [specify]: in other litigation concerning the custody of the same child(ren) in New York State Other State or other jurisdiction [specify]: . If so, specify type of case; whether party, witness or other; court, location, index or docket #, if known, and status of case: 12. [Check applicable box]: The following person(s) not party to these proceedings have claimed visitation rights to the child(ren) as follows: physical custody or I know of no person(s) not a party to the proceedings who claim(s) to have custody or visitation rights with respect to the child(ren) affected by this proceeding. 13. The custody or visitation of the child(ren) has been determined or agreed upon in the following instruments [specify court, if any, and date and attach true copy of instrument(s)]: Custody order of [specify court and location]: , dated [specify]: Stipulation of settlement in [specify court and location]: , dated [specify]: Judgment of Divorce of [specify court and location]: Separation Agreement, dated [specify]: , dated [specify]: Custody or Guardianship Agreement confirmed by [specify court and location]: , dated [specify]: 14. Petitioner Respondent obtained custody of the child(ren) on [specify date]: , as follows: 15. [Applicable to cases in which child protective petition or permanency hearing report has been filed regarding the children and in which petitioner is a relative or other non-parent; delete if inapplicable]: a. G A child protective petition, Docket # [specify]: , was filed in Family Court, [specify county]: on [specify date]: alleging that [specify names of respondents on that petition]: neglected or abused the above-named child(ren). The petition resulted in [specify whether finding was made and, if so, the disposition; if the disposition has been adjourned pending a consolidated hearing with this petition, pursuant to F.C.A. §1055-b, so indicate and give next court date]: b. G A permanency report, Docket # [specify]: , pursuant to Article 10-A of the Family Court Act, was filed in Family Court, [specify county]: on [specify date]: indicating a permanency plan of custody of the child(ren) with Petitioner in this proceeding. The permanency hearing was adjourned to [specify date]: pending a consolidated hearing with this petition, pursuant to F.C.A. §1089-a. c. The child’s birth mother Q has Q has not consented to the award of custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner’s standing to seek custody of American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-1 Page 5 the child(ren) [specify]: d. The child’s legally-established birth father Q has Q has not consented to the award of custody to the Petitioner. If not, the following extraordinary circumstances support Petitioner’s standing to seek custody of the child(ren) [specify]: e. The child has been living with the following foster parent(s)[specify]: since [specify date]: The foster parent(s) G has/have G has/have not consented to the award of custody to the Petitioner. [If unaware whether they have consented, so state]: f. The local department of social services [specify]: in the related Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award of custody to the Petitioner. [If unaware whether they have consented, so state]: g. The attorney for the child(ren) [specify]: in the related Q child abuse or neglect Q permanency proceeding Q has Q has not consented to the award of custody to the Petitioner. [If unaware whether they have consented, so state]: 16. It would be in the best interests of the child(ren) for Petitioner to have Q custody Q visitation for the following reasons [specify]: 17. The following circumstances have changed since entry of the other [specify]: of custody visitation [specify]: order judgment 18. An Order of Protection or Temporary Order of Protection was issued [check applicable box(es]: against Respondent against me in the following criminal, matrimonial or Family Court proceeding(s) [specify the court, docket or index number, date of order, next court date and status of case, if available]: The Order of Protection Temporary Order of Protection expired or will expire on [specify]: 19. Petitioner requests a Temporary Order of Protection pursuant to Family Court Act §655 because [specify]: 20. [Applicable where government agency is a party]: The subject child is is not a NativeAmerican child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicable box(es)]: parent/custodian [specify name and give notification date]: tribe/nation [specify name and give notification date]: United States Secretary of the Interior [give notification date]: 21. No previous application has been made to any court or judge for the relief herein requested, except [specify; delete if inapplicable]: WHEREFORE, Petitioner respectfully requests this Court to issue: A. An order awarding custody visitation of the above-named child(ren) to the Petitioner as American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-1 Page 6 follows [specify]: B. An order directing the Respondent to appear before the Court immediately with the abovenamed child(ren) for a hearing; C. A warrant for the Respondent to appear with the above-named children; D. An order directing the following temporary, emergency measures to protect the child, a parent or sibling [specify]: E. An order directing the following measures necessary to ensure the safety of the child and any person ordered to appear [specify]: F. An order directing the Respondent to pay Petitioner’s attorneys’ fees and costs, including reasonable and necessary travel expenses, for the prosecution of this proceeding; and G. A temporary order of protection containing the following condition(s) [specify]: H. An order directing such other and further relief as the Court may determine to be just and proper. Dated: _________________________ Petitioner _____________________________ Print or Type Name _____________________________ Signature of Attorney, if any ______________________________ Attorney’s Name (print or type) ______________________________ Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK ) COUNTY OF :ss: ) being duly sworn, says that (s)he is the Petitioner in the above-named proceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. __________________________ Petitioner Sworn to before me this day of (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkflow.com