PETITION INFORMATION SHEET

1) Petitioner (YOU)
**Name: Gladis Yolanda Sumba Arana Alias or Nickname: N/A
**Full Address (include apt# and zip code) : 3107 58th Street, Fl 3, Woodside, NY, 11377
** Do you want to keep your address confidential (private) from the person you are filing against?  Yes  No
Phone (home): ( N/A ) Phone (cell): ( 347 ) 640-8754 Email address: N/A
**Date of Birth: 08/20/1984
/ / **Sex:  Male  Female Soc. Sec. No.: N/A

Race:  White  Black  Native American  Asian / Pacific Islander Ethnicity:  Hispanic  Non – Hispanic

Height: 4'9 FT Weight: 163 LBS Eye Color: Brown Hair Color: Brown

2) I am related to the person(s) I am filing against as follows:  Married  Divorced  We have a child in common
 Parent  Child  We are related by Blood or Marriage (describe) ______________________________________
 Other Intimate Relationship (describe) ______________________________________________________________

3) Respondent (the person you are filing against) for guardianship cases list the child’s mother here
**Name: Alias or Nickname:

**Full Address (include apt# and zip code) :

Phone (home): ( ) Phone (cell): ( ) Email address:

**Date of Birth: / / **Sex:  Male  Female Soc. Sec. No.:
Race:  White  Black  Native American  Asian / Pacific Islander Ethnicity:  Hispanic  Non – Hispanic

Height: Weight: Eye Color: Hair Color:

Skin Complexion: Light  Medium Dark Tattoos / scars (location/description) _______________________________

Vehicle information: Make: _____________ Model:_________________ Year:______________ Color:__________

Employer/School: (list name /address )_________________________________________ Work School hours ___________

4) 2nd Respondent (the 2nd person you are filing against) for guardianship cases list the child’s father here

**Name: Wilmer Alejandro Banegas Cajamarca Alias or Nickname: N/A

**Full Address (include apt# and zip code) : 82-75 88th Place, Glendale, NY, 11385

Phone (home): ( N/A ) Phone (cell): ( N/A ) Email address: N/A

**Date of Birth: 04/20/1989
/ / **Sex:  Male  Female Soc. Sec. No.: N/A
Race:  White  Black  Native American  Asian / Pacific Islander Ethnicity:  Hispanic  Non – Hispanic

Height: 5'2FT Weight: 170LBS Eye Color: Brown Hair Color: Black
N/A
Skin Complexion: Light  Medium Dark Tattoos / scars (location/description) _______________________________
N/A
Vehicle information: Make: _____________ Model:_________________ Year:______________ Color:__________
N/A
Employer/School: (list name /address )_________________________________________ Work School hours ___________
5) If you were you married to (one of) the Respondent(s) what was the date of the Marriage: ______/______/______
What Country / State / County was the marriage held in? ________________________________________________

5a) If you were married; are you now divorced from the Respondent? Yes No If yes, please provide the date and
Country / State / County of the divorce: _______________________________________________________________

5b) If you were never married to the Respondent, and one of the respondent’s is the father of the child(ren), has
paternity been established by hospital declaration or court order of filiation? Yes No If yes, please provide the
Docket No. / Board of Health No.: _______________________ and County: __________________________
6) List all of the child(ren) that are the subject of your filing. If you are filing for an order of protection list all of the
children under 18 living with you in your home. Please provide the child’s current address and where the child has
lived for the past two years. I have no child(ren) and no other child(ren) live with me

Child #1’s name Date of Birth Sex Relation to the Respondent(s)

Luis Fernando Banegas Sumba 10/03/2006 Male Son
Child #1’s current address How long has child lived here?
3107 58th Street, Fl 3, Woodside, NY, 11377 from April
/ 2021
/ to PRESENT
/ /
Child#1’s prior addresses for the past two years How long did the child live there?
from / / to / /
from / / to / /
from / / to / /
from / / to / /

Child #2’s name Date of Birth Sex Relation to the Respondent(s)

Nataly Estefania Banegas Sumba 12/06/2007 Female Daughter

Child #2’s current address How long has child lived here?
3107 58th Street, Fl 3, Woodside, NY, 11377 from April
/ 2021
/ to / Present
/
Child#2’s prior addresses for the past two years How long did the child live there?
from / / to / /
from / / to / /
from / / to / /
from / / to / /

Child #3’s name Date of Birth Sex Relation to the Respondent(s)

Child #3’s current address How long has child lived here?
from / / to / /
Child#3’s prior addresses for the past two years How long did the child live there?
from / / to / /
from / / to / /
from / / to / /
from / / to / /
7) Are any of the children Native American Children subject to the Indian Child Welfare Act of 1978? Yes ❑ No ❑
 For all filings please complete Sections 1, 2, and 3
Custody / Visitation - fill in section 4, Modifications, Violation/Enforcements of custody / visitation - fill in Section 5
Writs of Habeas Corpus - fill in section 6, Uniform Child Custody Jurisdiction and Enforcement Act - fill in section 7
Guardianship - fill in section 8, if you need more space for an answer use the add-on form provided on the website
SECTION 1
Have there been any other proceedings in any court regarding what you are filing today? Yes  No 
If yes, where? ________________________What was the outcome? _______________________________________
Was there ever an Order of Protection issued against you or the other party by any Court? Yes  No 
If yes, when and where? ___________________________________________________________________________
Has ACS (Administration for Children’s Services) or any related agency been involved with any of above listed
parties/children? Yes  No  What County/Docket #: ________________________________________________
Do you have any knowledge of a report against you to the Statewide Register of Child Abuse? Yes  No 
If Yes, where? __________________________________________ when was it reported ? ______/______/________
SECTION 2
Luis and Nataly are currently living with me
Who do(es) the child(ren) currently live with :__________________________________________________________
I have always taken care of my children The father
How and when did you or the other party obtain physical custody of the child(ren) ? ___________________________
has not been present in their live since they arrived to my care.
_______________________________________________________________________________________________
❑ I have had the child(ren) since birth
SECTION 3
Are either you or the respondent  going into or  returning from military service? If Yes what Branch of the
military?  Army  Navy  Air Force  Marines  Coast Guard  National Guard  Other ________________
What is the anticipated date of service _____ /______ / ______ and length of service ________________________?
How will  being on /  returning from Active Duty likely affect your custody/visitation?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

SECTION 4 – Requests for custody and /or visitation

Why would it be in the child(ren)’s best interests for you to have custody/visitation?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

SECTION 5 – Requests for violation, enforcement or modification petitions

Explain how the order was violated and how you would like it enforced or how and why it should be modified:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 6 - Requests for writs of habeas corpus
 I have requested that the Respondent return the child(ren) to me and the Respondent has refused.
Date child(ren) was/were removed from your custody: _______/_______/________
Date child(ren) was/were expected to be returned to your custody (if relevant): _______/_______/________
Explain how the child(ren) was/were wrongfully removed from your custody:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Why would it be in the child(ren)’s best interests to be returned to you?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 7 - Requests for Uniform Child Custody Jurisdiction and Enforcement Act
Do(es) the child(ren) currently live in NY?  Yes  No
If no, has/have the child(ren) lived in NY within the last 6 months?  Yes  No
If yes, is one of the parents of the child still living in NY?  Yes  No If yes, where? _________________________
Has any other state declined to hear this custody / visitation matter?  Yes  No If yes, what state: ______________
Is there an emergency situation that exists that would give NY jurisdiction on a temporary basis?  Yes  No
If yes, what is the situation?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 8 - Guardianship
Is the Father still living? Yes ❑ No If the father is deceased please provide his date of death _____/_____/______
Is the Mother still living? Yes ❑ No If the mother is deceased please provide her date of death _____/_____/_____
N/A
If both parents are deceased who is the child’s next of kin? _______________________________________________
The respondent is the father of Luis and Nataly.
What is that person’s relationship to the subject child(ren)? _______________________________________________
I am their mother.
How are you related to the child(ren)?____________________ Catholic
What is the child’s religion? ____________________
To your knowledge has there ever been a guardian appointed for this child(ren)? ❑Yes ❑No if Yes, where?
_____________________________________________________________ when was it issued? _____/_____/______

Why would it be in the child(ren)’s best interest for you to have Guardianship?
_______________________________________________________________________________________________
It would be in the best interest of my children to remain in my care becuase I have supported them financially and
_______________________________________________________________________________________________

emotionally without the care of their father. Luis and Nataly has no one else besides me to care for them
_______________________________________________________________________________________________
The parent(s) if alive, should not be appointed guardian of the child(ren) because:
_______________________________________________________________________________________________
The father does not take care of Luis and Nataly. He has not provided for them financially and emotionally since they
_______________________________________________________________________________________________
have been in my care. The father no longer communicates with Luis and Nataly and has failed to be present in ther life.
____________________________________________________________________________________________