SURR-4-a Affidavit of independent witness to execution of extra-judicial surrender of child in foster care (non-agency employee), Surrender Forms, Subchapter A. Forms Authorized by Section 205.7, Chapter IV. Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7), Subtitle D. Forms, TITLE 22. Judiciary, New York Codes Rules Regulations

New York Codes Rules Regulations (Last Updated: March 27,2024)

Chapter IV. Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7)

Subchapter A. Forms Authorized by Section 205.7

Surrender Forms

SURR-4-a Affidavit of independent witness to execution of extra-judicial surrender of child in foster care (non-agency employee)

Soc. Serv. Law § 383-c(4)

Form SURR-4-a

(Affidavit of Independent Witness to

Execution of Extra-Judicial Surrender

of Child in Foster Care—Non-agency

Employee)

(9/2006)

FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF

________________

In the Matter of the Application for

Docket No.

Approval of a Surrender Instrument Concerning

AFFIDAVIT OF INDEPENDENT

WITNESS TO EXECUTION OF

EXTRA-JUDICIAL SURRENDER

CIN #

OF CHILD IN FOSTER CARE

Pursuant to Section 383-c of the Social Services Law

________________

STATE OF NEW YORK

)

) ss.:

COUNTY OF

)

I, [specify name of witness]:

, having been duly sworn, deposes and states the following:

1. [Check all applicable box(es)]:

□ I am an attorney at law duly licensed to practice under the laws of the State of New York and have an office at [specify address]:

□ I am a certified social worker duly licensed to practice under the laws of the State of New York and have an office at [specify address]:

□ I am [specify relationship, if any, to person executing surrender and/or child]:

I □ reside □ have an office at [specify residential or office address]:

2. On [specify date]:

, I witnessed the execution and acknowledgment of the surrender of the above-named child by [specify]:

at the following location [specify]:

3. I am not an employee, volunteer, consultant or agent of, or attorney for, the authorized agency to which the child is being surrendered and I do not serve as the sole non-employee witness for the agency. I am not an employee of an agency or organization contractually or financially responsible for or involved with the delivery of services to the above-named child or his or her family, nor am I related within the second degree to any employee-witness to the surrender of the child. Neither I nor my employer have received any payment or compensation other than actual and reasonable transportation expenses, if any, incurred in order to witness the surrender.

Form SURR-4-a Page 2

4. The person executing the surrender instrument was provided with a copy of the surrender and the surrender was read in full in his or her principal language of [specify]:

The person executing the surrender instrument was given an opportunity to ask questions and obtain answers regarding the nature and consequences of the surrender, including the consequences of, and procedures to be followed in, cases of a substantial failure of a material condition, if any, contained in the surrender instrument. The person executing the surrender instrument was informed of the obligation to provide the authorized agency with a designated mailing address, as well as any subsequent changes in such address, at which the person executing the surrender may receive notices regarding any substantial failure of a material condition, unless this notification is expressly waived by a statement written by the person executing the surrender instrument and appended to or included in the surrender instrument.

Signature of Independent Witness to Execution of Extra-judicial Surrender

Sworn to before me this

day of

_________ Notary Public (Deputy) Clerk of Court