At a Term of the Family Court of the State of New York

F.C.A § 1094 Form 10-C-3

(Destitute Child –Order for Services)

(9/2012)

At a term of the Family Court of the State of New York,

held in and for the County of ,

at , New York, on

P R E S E N T:

Hon.

Judge

______

In the Matter of Docket No.

ORDER FOR SERVICES

CIN # (Destitute Child)

A Child(ren) under the Age of Eighteen

Years Alleged to be Destitute

Parent(s) or Other Party/Parties

______

[Check applicable box(es)]:

❑ A petition under Article 10-C of the Family Court Act having been filed with this Court alleging that the above-named child(ren) is/are destitute; and

And it appearing that certain services or assistance will facilitate protection of the child(ren), rehabilitation of the family, and, as appropriate, the return of the child(ren) from foster care;

NOW, therefore, it is

❑ ORDERED that the Commissioner of Social Services of the County of

❑ provide ❑ arrange for the provision of the following services or assistance authorized or required to be made available under the county’s comprehensive annual services program plan currently in effect [specify]:

❑ AND IT IS FURTHER ORDERED that the Commissioner of Social Services report to the Court in writing on the implementation of this order as follows [specify frequency or date]:

ENTER

______

Dated:,. Judge of the Family Court

PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST.

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]:______