Office of Children and Family Services | Home | OCFS
NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESAFFIDAVIT OF RELATIONSHIPI, FORMTEXT ?????affirm that the information provided here in is correct:(Print name(s) of Foster Parent(s))I FORMCHECKBOX a.) am related by blood, marriage or adoption, OR FORMCHECKBOX b.) am related by blood, marriage or adoption to a half-sibling, and am also the prospective or appointed relative guardian of such half-sibling. OR FORMCHECKBOX c.) have a positive relationship established prior to the child’s current foster care placement, with/to FORMTEXT ?????placed in my home on FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????as described below.(Name of child)(Date) FORMCHECKBOX I am related to the child’s mother. FORMCHECKBOX I am related to the child’s father. FORMCHECKBOX The child’s father and mother were married to each other when the child was born. FORMCHECKBOX The child’s father and mother were not married to each other when the child was born. FORMCHECKBOX I am related to the child’s half-sibling(s).* FORMCHECKBOX I am unrelated to the child and have a positive relationship with the child, that was established prior to the current foster care placement.* Describe this relationship: FORMTEXT ?????I am related to the child placed in my home, or the child’s half-sibling, as the: (Check all that apply) FORMCHECKBOX Grandfather FORMCHECKBOX Uncle FORMCHECKBOX Adult Brother FORMCHECKBOX Grandmother FORMCHECKBOX Aunt FORMCHECKBOX Adult Sister FORMCHECKBOX Great-grandfather FORMCHECKBOX Great-uncle FORMCHECKBOX Adult step-brother FORMCHECKBOX Great-grandmother FORMCHECKBOX Great-aunt FORMCHECKBOX Adult step-sister FORMCHECKBOX Step-father FORMCHECKBOX Nephew FORMCHECKBOX First cousin FORMCHECKBOX Step-mother FORMCHECKBOX Niece FORMCHECKBOX Second cousin FORMCHECKBOX Spouse of one of the above FORMCHECKBOX Other (explain): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature of Prospective Relative GuardianSignature of Prospective Relative GuardianSworn to before me Sworn to before me this FORMTEXT ?????day of FORMTEXT ?????,20 FORMTEXT ?????this FORMTEXT ?????day of FORMTEXT ?????,20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Notary PublicNotary Public If needed, the worker may ask you to draw a family tree on the back of this affidavit which shows all marriages and births necessary to demonstrate the relationships described above. If the worker does, please give complete names and approximate birth and marriage dates to the best of your ability. *If attesting to being related to a half-sibling of the child or to having a positive relationship established prior to the child’s current foster care placement, the casework progress notes demonstrating such relationship must also be included as documentation. ................
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