D.R.L. Art. 5-A Form UCCJEA-9 (Petition to Modify Custody or Visitation Order – UCCJEA) 3/2009 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ..................................................................................... In The Matter of a Proceeding to Modify a “ Custody “ Visitation Order under the Uniform Child Custody Jurisdiction and Enforcement Act Docket No. Petitioner PETITION TO MODIFY “ CUSTODY “ VISITATION ORDER – UCCJEA -againstRespondent ....................................................................................... TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges upon information and belief that: 1. I am [specify relationship to child; if foster parent, agency, institution or other relationship, so state] : . I [check applicable box]: “ reside “ am located at [specify /1 address]: I am seeking to modify the following order of “ custody “ visitation, a certified copy of which is attached [specify jurisdiction, court, docket or index number and date of order]: 2. Respondent , , [check applicable box]: “ resides “ is located at [specify /2 address]: Respondent is [specify relationship to child; if foster parent, agency, institution or other relationship, so state]: 3. The name, present address, and date of birth of each child who is the subject of this proceeding are as follows [Indicate if address ordered to be kept confidential pursuant to Domestic Relations Law §§76-h(5), 254 or Family Court Act §154-b(2)]: Name Present Address Date of Birth 1 Specify if address, telephone or other identifying information has been ordered to be kept confidential pursuant to New York State Domestic Relations Law §§76-h(5), 254 or Family Court Act §154-b. If your health or safety or that of your child or children would be put at risk by disclosure of your address or other identifying information, you may apply for an address confidentiality order by submitting General Form GF-21. This form is available on-line at www.nycourts.gov . 2 See note #1. American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-9 Page 2 4. [Applicable when Petitioner and/or Respondent are on active duty or have recently returned from active military service; DELETE if inapplicable]: a.. Petitioner [check applicable box]: Q 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]:/3 Q 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 return from active duty is likely to affect custody or visitation, if at all]: b. Respondent [check applicable box]: Q 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]:/4 Q 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 return from active duty is likely to affect custody or visitation, if at all]: 5. This order [check applicable box]: “ was issued by a New York State court. “ has been registered in New York State. [Attach copy of Order or Certification of Registration. Note: registration is not required]. “ has not been registered in New York State. “ was denied registration in New York State on [specify date]: by [check applicable box]: “ this Court “ another New York State court [specify]: “ is the subject of a pending application for registration in New York State filed on [specify date]: in [check applicable box]: “ this Court “ another New York State court [specify]: 6. This order [check applicable box]: “ has been registered in the following state, tribal or territorial jurisdiction or country [specify]: [Note: registration is not required.]. “ has not been registered in any other jurisdiction or country. “ was denied registration in the following state, tribal or territorial jurisdiction or country [specify]: “ is the subject of a pending application for registration in the following state, tribal or territorial jurisdiction or country [specify]: 7. This order is in effect and has not been vacated, stayed or modified. 3 Inapplicable if Petitioner is based at a permanent duty station or has had a permanent reassignment of station. 4 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-9 Page 3 8. [Applicable where the judgment or order had been entered in conjunction with a New York child protective dispositional or permanency hearing order directing custody with a relative or other nonparent, pursuant to Family Court Act §1055-b or §1089-a; delete if inapplicable]: a. The Gjudgment Gorder was issued in conjunction with the following child protective or permanency proceeding [specify Family Court, county and docket #]: b. The Gjudgment Gorder provided that the following local department of social services [specify]: and the following attorney for the child(ren)[specify]: must be notified and shall be made parties to any subsequent proceedings for modification, enforcement or termination of the judgment or order. Name 9. During the last five years, each child who is the subject of this proceeding resided at: Address/5 Duration Name of Person Current Address of (from/to) With Whom Child the Person With Whom Resided Child Resided 10. Apart from the proceeding that resulted in the issuance of the order sought to be modified herein, 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, capacity of participation, court, location and status of case: 11. [Check applicable box]: “ The following person(s) not party to these proceedings have claimed “ physical custody or “ visitation rights to the child(ren) as follows: “ 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. 12. a. It is in the best interests of the child(ren) that this order be modified as follows for the following reasons [specify]: b. “ This Court should modify the order on a temporary, emergency basis, pursuant to Domestic Relations Law §76-c, because the child(ren) (is) (are) presently in this State and [check one or both boxes]: “ the child(ren) (has)(have) been abandoned; “ it is necessary in an emergency to protect the child(ren), a sibling or siblings or parent of the child(ren). 13. The following circumstances affecting the child(ren) have changed since the order was originally issued [specify]: 5 See note #1 . American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-9 Page 4 14. Check applicable box: “ 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 of proceeding and status]: 15. The court that issued the order sought to be modified identified the following jurisdictional basis or bases for its issuance [check applicable box(es)]: “ The child lived in that state or jurisdiction with a parent or person acting as a parent for at least six consecutive months before the proceeding was commenced. “ The child and at least one parent or person acting as a parent had a significant connection with that state or jurisdiction and that state or jurisdiction has substantial evidence concerning the child’s care, protection, training and personal relationships. “ All other courts with jurisdiction declined to exercise jurisdiction and the court that issued the order determined that it was the more appropriate forum. “ No court of any other state or jurisdiction would have jurisdiction based upon any of the foregoing factors. “ No jurisdictional basis for the order was specified. 16. This Court has jurisdiction to modify the order on the following ground(s) [check applicable box(es)]: a. “ This Court has jurisdiction to make an initial determination of custody or visitation and [check one or both boxes]: “ The court of the other state has determined that it no longer has exclusive, continuing jurisdiction; or a court of this State would be a more convenient forum; and/or “ A court of this State or a court of the other state has determined that the child, the child’s parents and any other person acting as a parent do not presently reside in the other state; b. “ This Court should determine that the other state no longer has exclusive continuing jurisdiction, because [check applicable box]: “ Neither the child, the child’s parents nor any other person acting as a parent presently reside in the other state; or “ Other [specify]: c. “ This Court should determine that the court of the other state would be an inconvenient forum based upon the following factors [check applicable box(es)]: “ Domestic violence or mistreatment or abuse of a child or sibling has occurred and is likely to occur in the future [specify facts and circumstances, including date(s) and status of litigation, if any]: “ This Court would best be able to protect the parties and the child(ren) for the following reason(s) [specify]: “ the length of time the child(ren) (has)(have) resided outside this state [specify]: “ the distance between this Court and the court of the other state [specify]: “ the relative financial circumstances of the parties [specify]: “ any agreement of the parties as to which state should assume jurisdiction [specify and attach copy]: “ the nature and location of the evidence required to resolve the litigation, American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-9 Page 5 including testimony of the child [specify]: “ the abilities of this Court and the court of the other state to decide the issue expeditiously and the procedures in each state necessary to present the evidence [specify]: “ the familiarity of this Court and the court of the other state with the facts and issues in the pending litigation. 17. [Delete if inapplicable]: This court should issue a warrant requiring the production of the child because [check applicable box(es)]: “ The child is at imminent risk of serious physical harm because [specify]: “ The child is at imminent risk of removal from the State of New York because [specify]: 18. Petitioner requests a Temporary Order of Protection pursuant to Family Court Act §655 because [specify]: 19. [Applicable where government agency is a party]: The subject child “ is “ is not a Native-American 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]: 20. No previous application has been made to any court or judge for the relief herein, (except [specify]: WHEREFORE, Petitioner requests that this Court issue [check applicable boxes]: “ an order modifying the order of custody or visitation as follows [specify]: “ an order modifying the order of custody or visitation on a temporary, emergency basis as follows [specify]: “ an order convening a hearing on this petition; “ an order directing Respondent to immediately appear before the Court with the above-named child(ren); “ a warrant directing law enforcement to pick up the child(ren) and give physical custody to Petitioner or [specify]: “ an order necessary to ensure the safety of the parties and the child(ren) as follows [specify]: “ a temporary order of protection containing the following condition(s) [specify]: “ an order directing Respondent to pay Petitioner’s attorney’s fees and costs. “ an order [specify]: “ an order providing such other and further relief as this Court may deem just and proper. Dated: Signature of Petitioner American LegalNet, Inc. www.FormsWorkflow.com Form UCCJEA-9 Page 6 Petitioner’s Name (print or type) Signature of Attorney, if any Attorney’s Name (print or type) Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK ) :ss: COUNTY OF ) 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