homelesspetition
FORM NOTICE
STATE OF NEW YORK
STATE EDUCATION DEPARTMENT
__________________________________________________________x
In the Matter of ________________________________________
(parent’s/guardian’s/ unaccompanied youth’s name
otherwise known as "petitioner") on behalf of ________________________
______________________________ (child’s/youth’s name),
a homeless child or youth, from action of the Board of Education of the
________________________________________
______________________________________ School District
("respondent") regarding the provision of education and related services.
__________________________________________________________x
NOTICE:
The respondent is hereby required to appear in this appeal and to answer the allegations contained in the petition. Your answer must conform with the provisions of the regulations of the Commissioner of Education relating to appeals before the Commissioner of Education, copies of which are available from the Office of Counsel, New York State Education Department, State Education Building, Albany, New York 12234.
If an answer is not served and filed in accordance with the provisions of such rules, the statements contained in the petition will be deemed to be true statements, and a decision will be rendered thereon by the Commissioner.
Please take notice that such rules require that an answer to the petition must be served upon the petitioner, or if he be represented by counsel, upon his counsel, or if the petitioner so elects, the respondent shall serve the answer upon the local educational agency liaison for homeless children and youth, within 20 days after the service of the appeal, and that a copy of such answer must, within five days after such service be filed with the Office of Counsel, New York State Education Department, State Education Building, Albany, New York 12234.
Please take further notice that the within petition contains an application for a stay order. Affidavits in opposition to the application for a stay must be served on all other parties and filed with the Office of Counsel within three business days after service of the petition.
PETITION
STATE OF NEW YORK
STATE EDUCATION DEPARTMENT
________________________________________________________x
In the Matter of __________________________________
(parent’s/guardian’s/unaccompanied youth’s name
otherwise known as "petitioner") on behalf of PETITION
______________________________ (child’s/youth’s name),
a homeless child or youth, from action of the Board
of Education of the _______________________________
School District ("respondent") regarding the provision
of education and related services.
________________________________________________________x
TO THE COMMISSIONER OF EDUCATION:
My name is _____________________________________________.
Please check and complete one of the following statements.
[ ] I am a homeless child or youth.
OR
[ ] My relationship to _____________________________(child’s/youth’s name)
is_____________________________________________________________.
_________________________ (child’s/youth’s name) is a "homeless child" as defined by §100.2(x) of the Regulations of the Commissioner of Education.
____________________________ (child’s/youth’s name) is over 3 and under 21 years of age and has not received a high school diploma.
On ________________ (date), _______________________ (child’s/youth’s name) made a request for
(Check applicable boxes)
[ ] enrollment in a school or a school program,
[ ] transportation,
[ ] other (please specify] ____________________________________________
__________________________________________________________________
to the ________________________________ School District.
The above request was denied by respondent on ____________________________ (date).
(Attach copy of denial if available)
Please check and complete all that apply:
The named child/youth is a homeless child because he/she lacks a fixed, regular, and adequate nighttime residence and
[ ] is sharing the housing of other persons due to loss of housing, economic hardship or a similar reason.
Please list name, address and relationship of all persons with whom the child/youth is sharing housing. (Attach additional sheets if necessary.)
_______________________________________________________________________
_______________________________________________________________________
[ ] is living in motels, hotels, trailer parks or camping grounds due to the lack of alternative adequate accommodations.
[ ] was abandoned in a hospital.
[ ] is awaiting foster care placement.
[ ] is a migratory child.
[ ] other (please specify) _________________________________________
The named child/youth has a primary nighttime location that is:
[ ] a supervised, publicly or privately operated shelter designed to provide temporary living accommodations, such as a shelter operated or approved by the State or local department of social services or residential programs for runaway and homeless youth.
List name and address of shelter (The name and address of the shelter is not required if child’s/youth’s primary nighttime location is a domestic violence shelter):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
[ ] a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation, such as a car, park, public space, abandoned building, substandard housing, bus or train stations or similar settings.
Describe child’s/youth’s current living arrangements indicated above: (Attach any relevant documents and add additional pages as necessary.)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
List address of child’s/youth’s last permanent residence:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
10. Prior to becoming homeless, ___________________________ (child’s/youth’s name) was attending, or entitled to attend,
the _________________________ School District on a tuition-free basis.
11. Describe the circumstances causing child/youth to become homeless: (Attach any relevant documents and add additional pages if necessary.)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
12. Since ________________________________ (child’s/youth’s name) became
homeless, he/she has attended the following school districts. (If known, list
the approximate dates of attendance at each school district listed.)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
13. List names and address(es) of child’s/youth’s parent(s) or legal guardian(s):
__________________________________________________________________________
__________________________________________________________________________
14. Are child’s/youth/s parent(s) or legal guardians homeless? ( Check one.)
[ ] yes [ ] no
IF THE CHILD/YOUTH LIVES WITH SOMEONE OTHER THAN HIS/HER PARENTS OR LEGAL GUARDIANS, COMPLETE PARAGRAPHS 16 – 19. OTHERWISE, GO TO PARAGRAPH 20.
15. __________________________________ (name of appropriate individual(s) is/are providing support for
_____________________________________________ (child’s/youth’s name).
16. ______________________________ (name of appropriate individual)
exercises control over __________________________’s (child’s/youth’s name)activities and behavior.
17. ________________________’s (child’s/youth’s name)parent(s) has surrendered parental control
over_______________________________________ (child’s name) to
______________________________ (appropriate individual), if applicable.
18. Describe the nature of child’s/youth’s relationship with parents/legal guardians, such as the last contact, frequency and nature of contacts, etc.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
19. Please check and complete one of the following statements:
[ ] _______________________(child’s/youth’s name) is currently attending
the___________________________________________________School District.
OR
[ ] _________________________(child’s/youth’s name) has not been attending school or receiving any educational services
since _____________(date).
20. (Check one box.)
[ ] I am [ ] I am not designating the liaison for homeless children and youth of the respondent school district to receive and hold correspondence regarding this appeal.
21. Address to which correspondence regarding this appeal should be sent: (If the liaison is designated, list the liaison’s address.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
WHEREFORE, I respectfully request: (Complete all that apply)
An immediate order from the Commissioner permitting _______________________
_______________(child’s/youth’s name) to attend the________________________
School District with transportation provided/arranged by such school district
pending a decision on the merits of this appeal.
2. A determination that _____________________ (child’s/youth’s name) is a
homeless child entitled to attend the _____________________________________
School District without the payment of tuition.
3. A determination that ______________________ (child’s/youth’s name) is a
homeless child entitled to transportation provided by the _________________
_____________________ School District.
4. Such other relief as the Commissioner deems just and proper.
5. Other (please specify)
______________________________________________________________________________
______________________________________________________________________________
DATE: ________________________________________________________________________
List your name, address and phone number OR the name, address and phone number of the homeless liaison.
NAME: ________________________________________________________________________
ADDRESS: _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PHONE: _______________________________________________________________________
ATTACH ANY SUPPORTING AFFIDAVITS AND EXHIBITS.
STATEMENT OF PETITIONER CONCERNING A HOMELESS CHILD OR YOUTH
NOTE: THE FOLLOWING STATEMENT MUST BE COMPLETED AND SUBMITTED WITH THE NOTICE OF PETITION AND PETITION CONCERNING A HOMELESS CHILD OR YOUTH
___________________________(name of petitioner) states that he/she is the petitioner in this proceeding and is the parent or guardian of a homeless child or youth or is an unaccompanied youth as defined by §100.2(x) of the regulations of the Commissioner of Education; that he/she has read the annexed petition and any supporting affidavits or exhibits and knows the contents thereof; that the same is true to his/her knowledge except as to the matters therein stated to be alleged upon information and belief, and as to those matters he/she believes it to be true and further acknowledges that he/she is aware of the fact that, pursuant to Penal Law §175.30, a person who knowingly offers a false instrument for filing to a public official or public servant is guilty of Offering a False Instrument for Filing in the 2nd Degree, a Class A Misdemeanor.
__________________________________
Petitioner’s Signature
____________________
Date