384-4 Order approving of denying surrender instrument (child not in foster care)  

Soc. Serv. Law §§ 384, 384-c

Form 384-4

(Order-Approval of

Surrender Instrument)

12/97

At a term of the Family Court of the

State of New York, held in and for the

County of

,

at

, New York

on

 

, 19

.

P R E S E N T:

Hon. Judge

In the Matter of the Application for Approval

Docket No.

of a Surrender Instrument concerning

Pursuant to Section 384 of the

Social Services Law

The petition of

 

an authorized agency dated the

 

day of

 

, 19

 

, having been filed requesting Court approval of an instrument of surrender executed on the

 

day of

 

, 19

 

, committing the guardianship of the person and custody of

 

, a child under the age of eighteen years to

 

, an authorized agency and

(parents) (guardians) having been duly served with notice of this proceeding and having (personally) appeared before this Court with (out)(by) counsel, (failed to appear) (having by instrument consented to the jurisdiction of this Court, and having waived service of the petition and notice of proceeding and the Court having dispensed with such service); (and a law guardian having been appointed to represent the child) and

ORDERED that the petition herein is hereby (GRANTED)(DENIED), and the instrument dated

 

, executed by

, is hereby (approved)(disapproved); and it is further

ORDERED that a copy of this Order shall be served (personally) (by certified mail) by the Petitioner upon the (parent(s)) or (guardian(s)) who executed the aforesaid instrument of transfer.

Such service shall be made within

days from the date hereof, together with a notice of the terms and conditions, if any, under which the custody and guardianship of such child may be returned to the (parent(s)) (guardian(s)). [Delete inapplicable provisions]

Dated:

 

, 19

.

Check applicable box:

□ Order mailed on [specify date(s) and to whom mailed]:

□ Order received in court on [specify date(s) and to whom given]: