Child Custody & Visitation Form GF-17

Case Information

County Proceeding Type Family Court Act Article Family File Number Docket Number Petitioner Name Petitioner Relationship to Child Respondent Name Respondent Relationship to Child Petition Requested

1. Children

Child 1 Name Child 1 Gender Child 1 Date of Birth Child 1 Current Address Person With Whom Child 1 Resides Child 2 Name Child 2 Gender Child 2 Date of Birth Child 2 Current Address Person With Whom Child 2 Resides

2. Petitioner Information

Petitioner Name Petitioner Location Type Petitioner Address Petitioner Relationship to Child

3. Respondent Information

Respondent Name Respondent Location Type Respondent Address Respondent Relationship to Child

4. Prior Residence of Children

Is Paragraph 4 Applicable? Child 1 Name Child 1 Previous Address Duration Person With Whom Child Resided Current Address of That Person Child 2 Name Child 2 Previous Address Duration Person With Whom Child Resided Current Address of That Person

5. Military Service

Petitioner is on active duty, deployed, or temporarily assigned Petitioner Active Duty Details Petitioner recently returned from active duty Petitioner Returned Duty Details Respondent is on active duty, deployed, or temporarily assigned Respondent Active Duty Details Respondent recently returned from active duty Respondent Returned Duty Details

Court Referral

An order was issued referring custody or visitation to Family Court Referring Court Name County State Issue Referred New York Family Court County

6. Parentage Information

Father is identified Father Name Father was married to the mother at conception or birth An order of filiation was made Filiation Order Details An Acknowledgment of Parentage was signed Acknowledgment Date Who Signed the Acknowledgment Father is deceased Parentage Agreement County Parentage Agreement Month Parentage Agreement Day / Year Parties / Children in Parentage Agreement

7. Parent Not a Party

Name and Address of Parent(s) Not a Party

8. Other Custody Litigation

Participation Type Other Capacity Jurisdiction Other Jurisdiction Case Details

9. Pending Custody / Visitation Proceedings

Proceeding Pending in New York? New York Proceeding Details Proceeding Pending Outside New York? Outside New York Proceeding Details

10. Custody / Separation / Guardianship Agreement

Is There an Agreement? Agreement Date Agreement Details

11. Previous Custody or Visitation

Who Obtained Custody? Custody Date Custody Details Who Obtained Visitation? Visitation Date Visitation Details

12. Best Interests of the Children

Petitioner Requests Reasons

13. Orders of Protection

Order Issued Against Protection Order Proceeding Details Protection Order Type Expiration Date Reason for Temporary Order of Protection Request

14. Indian Child Welfare Act

Are the Children Native-American Children Potentially Subject to ICWA? Parent / Custodian notified Parent / Custodian Notification Details Tribe / Nation notified Tribe / Nation Notification Details United States Secretary of the Interior notified Secretary Notification Date

16. Previous Application

Previous Application Exception Requested Final Relief Dated Upload Petitioner Signature

Signature and Verification

Print or Type Petitioner Name Attorney Signature, if any Attorney Name Attorney Address and Telephone Number

Verification

Verification Day Verification Month Verification Year Upload Verification Signature

Paragraph 17 Addendum

Child protective petition Child Protective Docket Number County Date Filed Respondents Named in Petition Finding / Disposition Destitute child petition Destitute Child Docket Number County Date Filed Finding / Disposition Permanency report Permanency Docket Number County Date Filed Permanency Hearing Adjourned Date Termination of placement/remand will not jeopardize child safety Reasons

Other Parent Consent Non-Parent Name Non-Parent Objection Birth Mother Consent Birth Mother Extraordinary Circumstances Birth Father Consent Birth Father Extraordinary Circumstances

Foster Parent Information

Foster Parent Name(s) Child Has Lived With Foster Parent Since Foster Parent Consent If Consent Is Unknown, Explain

Department of Social Services

Local Department of Social Services Child abuse or neglect proceeding Destitute child proceeding Permanency proceeding DSS Consent If Consent Is Unknown, Explain

Attorney for the Child or Children

Attorney Name Child abuse or neglect proceeding Destitute child proceeding Permanency proceeding Attorney Consent If Consent Is Unknown, Explain

General Form 17 - Custody / Visitation Petition