N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. IV, subch. A, Child Protective Forms (Family Court Act Article 10), form 10-11b - Affidavit in support of motion to terminate placement

F.C.A.§ 1062 Form 10-11b

(Child Protective-Affidavit in

Support of Motion

To Terminate Placement)

(9/2006)

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

________

In the Matter of

Docket No.

CIN #

A Child under Eighteen Years of

Age alleged to be

Abused Neglected by AFFIDAVIT IN SUPPORT OF

MOTION TO

TERMINATE PLACEMENT

Respondent(s)

________

STATE OF NEW YORK)

) SS.:

COUNTY OF NEW YORK)

, swears the following to be true under the penalties of perjury:

1. I am the parent other interested person[specify relationship to child]: of [specify child]: I am making this affidavit in support of the motion to terminate the child's placement.

2. (Upon information and belief,) the above-named child, was removed from (his)(her) home on [specify date]: and was placed in foster care on [specify date]:, as a result of a proceeding under Article 10 of the Family Court Act. Custody of the child remains with [specify]:

3. I made a request to [specify social services or agency official]: to terminate the child's placement and return the child to my home on [specify date]: . That request was denied on [specify date]: not granted within 30 days of my request.

4. The child's placement should be terminated and the child should be returned to my home for the following reasons [specify]:

Form 10-11b Page 2

5. No previous application has been made to any court or judge for this relief (except [specify]:).

WHEREFORE, I respectfully request that an Order be made herein terminating the placement of the above-named child, returning the child to my home and granting such other and further relief as the Court may deem just and proper.

______________

Affiant

Sworn to before me this day of ,

______________

(Deputy) Clerk of the Court

Notary Public

Notes

N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. IV, subch. A, Child Protective Forms (Family Court Act Article 10), form 10-11b