Petition Form Ny (Page 4 of 6) in pdf

Petition Form Ny Page 4

General Form 17 Page 4

box(es]: “ against Respondent “ against me in the following criminal, matrimonial and/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 date ]:

b. “ Petitioner requests a Temporary Order of Protection pursuant to Family Court Act §655

because [specify]:

15. [Applicable where one or more parties are not parents of the child(ren); if not, SKIP to

Paragraph 16]]: The subject child(ren) “ are “ are not Native-American child(ren) who may be subject

to the Indian Child Welfare Act (25 U.S.C. §§ 1901-1963).

16. [INSERT ADDENDUM where a child abuse, child neglect or destitute child petition

and/or a permanency hearing report has been filed regarding the child(ren) and in which Petitioner

is a Respondent parent, Non-respondent parent, relative or other non-parent; if not, SKIP to

Paragraph 17].

17. No previous application has been made in any court, including a Native-American tribunal, or

to any judge for the relief herein requested, (except:

WHEREFORE, Petitioner requests an order awarding “ custody “ visitation of the child(ren) to the

Petitioner and for such other and further relief as the Court may determine.

Dated:

____________________________

Petitioner

____________________________

Print or type name

____________________________

Signature of Attorney, if any

____________________________

Attorney’s Name (Print or Type)

____________________________

Attorney’s Address and Telephone Number

Petition Form Ny Page 4