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FORM NOTICE OF PETITION CONCERNING A HOMELESS CHILD OR YOUTH

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.

 

FORM PETITION
CONCERNING A HOMELESS CHILD OR YOUTH

 

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

 

 

TO THE COMMISSIONER OF EDUCATION:

 

1.    My name is ______________________________________________________.

2.    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___________________________________________________________________.

 

3.    _________________________ (child’s/youth's name) is a "homeless child" as defined by §100.2(x) of the Regulations of the Commissioner of Education.

4.    ____________________________ (child's/youth's name) is over 3 and under 21 years of age and has not received a high school diploma.

5.    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.

 

6. The above request was denied by respondent on ____________________________ (date).

(Attach copy of denial if available)

 

7. 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.

8.  Describe child’s/youth's current living arrangements indicated above: (Attach any relevant documents and add additional pages as necessary.)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

9. 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)

 

1. 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.