New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter VII - Surrogate's Court Forms › Subchapter B - Adoption Forms Of The Surrogate's Court › Adoption Forms › Form 2-G - Extrajudicial consent (birth or legal parent - private-placement)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 115, 115-b Form
						2-G
(Extrajudicial Consent -
Birth or Legal Parent --
Private-placement)
12/97
COURT OF THE STATE OF NEW YORK
COUNTY OF
________
In the Matter of the Adoption of
						(Docket)(File) No.
A Child Whose First Name is
EXTRAJUDICIAL CONSENT
(Birth or Legal Parent--
Private Placement)
________
THIS CONSENT MAY BE REVOKED WITHIN 45 DAYS
						OF THE EXECUTION OF THIS DOCUMENT. IF THE CONSENT IS NOT REVOKED WITHIN SAID 45
						DAYS, NO PROCEEDING MAY BE MAINTAINED BY THE PARENT FOR THE RETURN OF THE
						CUSTODY OF THE CHILD. THE REVOCATION MUST BE IN WRITING AND RECEIVED BY THE
						COURT WHERE THE ADOPTION PROCEEDING IS TO BE COMMENCED WITHIN 45 DAYS OF THE
						EXECUTION OF THE CONSENT. THE NAME AND ADDRESS OF THE COURT IN WHICH THE
						ADOPTION PROCEEDING HAS BEEN OR IS TO BE COMMENCED IS
.
IF THE ADOPTIVE PARENTS CONTEST THE
						REVOCATION, TIMELY NOTICE OF REVOCATION WILL NOT NECESSARILY RESULT IN THE
						RETURN OF THE CHILD TO THE PARENT, AND THE RIGHT OF THE PARENT TO THE CUSTODY
						OF THE CHILD WILL NOT BE SUPERIOR TO THOSE OF THE ADOPTIVE PARENTS. A HEARING
						BEFORE A JUDGE WILL BE REQUIRED TO DETERMINE: (1) WHETHER THE NOTICE OF
						REVOCATION WAS TIMELY AND PROPERLY GIVEN; AND IF NECESSARY, (2) WHETHER THE
						BEST INTERESTS OF THE CHILD WILL BE SERVED: (A) BY RETURNING CUSTODY OF THE
						CHILD TO THE PARENT; OR (B) BY CONTINUING THE ADOPTION PROCEEDING COMMENCED BY
						THE ADOPTIVE PARENTS; OR (C) BY DISPOSITION OTHER THAN ADOPTION BY THE ADOPTIVE
						PARENTS; OR (D) BY PLACEMENT OF THE CHILD WITH AN AUTHORIZED AGENCY. IF ANY
						SUCH DETERMINATION IS MADE, THE COURT WILL MAKE SUCH DISPOSITION OF THE CUSTODY
						OF THE CHILD AS WILL BEST SERVE THE INTERESTS OF THE CHILD.
Form 2-G Page 2
THE PARENT HAS THE RIGHT TO LEGAL
						REPRESENTATION OF THE PARENT'S OWN CHOOSING, THE RIGHT TO SUPPORTIVE COUNSELING
						AND MAY HAVE THE RIGHT TO HAVE THE COURT APPOINT AN ATTORNEY PURSUANT TO
						SECTION
						262 OF THE
						FAMILY COURT ACT, SECTION
						407 OF THE SURROGATE'S COURT PROCEDURE ACT,
						OR SECTION
						35 OF THE
						JUDICIARY LAW.
1. I [specify name]:
, residing at
, (birth) (legal) parent of [specify
						first
name of child]: do hereby consent to the
						adoption of my
(daughter) (son) who was, born on [specify
						date]: ,
(by [specify name]:
, adoptive parent(s)).
2. The full name and last known address of
						the other (birth) (legal) parent of the adoptive child are:
3. I have (not) been represented by
						counsel. (If represented, state counsel's name, address and telephone
						number:
.)
Date:
/
_________________________
(b) . The adoptive parent(s) (has)(have)
						(no) knowledge of any criminal record concerning themselves or any other adult
						residing in the household (except)
/
_________________________
Adoptive Parent: typed or printed
						name/signature
/
_________________________
Adoptive Parent: typed or printed
						name/signature
/
_________________________
Adoptive child if over 18: typed or
						printed name/signature
/
_________________________
Attorney if any: typed or printed
						name/signature
_________________________
Attorney's Address and Telephone
						number
Form 2-g Page 3
STATE OF NEW YORK)
: ss.:
COUNTY OF)
On this day of, 19,, the person who
						executed the foregoing instrument, personally came before me and acknowledged
						that (he)(she) acknowledged that (he) (she) executed the same.
______________
Notary Public