New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter IV - Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) › Subchapter B - Adoption Forms Of The Family Court › Adoption Forms › Form 2-A - Agreement of adoption and consent (agency)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 111 (1)(f), 112(2)(b),
						Form 2-A
113 (Agreement of Adoption and
						Consent--Agency)
8/2002
FAMILY 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
AGREEMENT OF
ADOPTION AND
CONSENT (Agency)
________
The undersigned petitioning adoptive
						parent(s) hereby agree(s) to adopt the above-named adoptive child and to treat
						said child in all respects as (his) (her) (their) own lawful child and to
						extend and assure to said child all the rights, benefits and privileges
						incident to such relationship, and to incur and fulfill all the
						responsibilities of (a parent) (parents) with respect to said child.
Dated:
/
_________________________
Adoptive Parent: typed or printed
						name/signature
/
_________________________
Adoptive Parent: typed or printed
						name/signature
/
_________________________
Adoptive child if over 14: typed or
						printed name/signature
/
_________________________
Attorney if any: typed or printed
						name/signature
_________________________
Attorney's Address and Telephone
						number
Form 2-A Page 2
The undersigned authorized agency hereby
						consents to the adoption of the above-named adoptive child by the petitioning
						adoptive parent(s).
Name of Authorized Agency: ________
By: ________
______________
Title
STATE OF NEW YORK)
ss:
COUNTY OF)
On [specify date]:, [specify name]:
						personally appeared before me. (He)(She) is personally known to me or proved
						(his)(her) identity to me by satisfactory evidence as the person whose name is
						subscribed on this agreement of adoption and consent. (He)(She) acknowledged to
						me that (he)(she) executed this agreement and consent.
______________
Notary Public
STATE OF NEW YORK)
ss:
COUNTY OF)
On [specify date]:, [specify name]:
						personally appeared before me. (He)(She) is personally known to me or proved
						(his)(her) identity to me by satisfactory evidence as the person whose name is
						subscribed on this agreement of adoption and consent. (He)(She) acknowledged to
						me that (he)(she) executed this agreement and consent.
______________
Notary Public
Form 2-A Page 3
STATE OF NEW YORK)
ss:
COUNTY OF)
On this day of,, before me personally
						came, to me known and who by me being duly sworn did depose and say:
That he/she resides at
County of State of :
that he/she is [specify position]:
of [specify authorized agency]:
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
______________
Notary Public
State of New York)
ss.:
County of)
On this day of, ,
, proven to me by the oath of ,
an attorney admitted to practice in the
						State of New York, to be the person who executed the foregoing instrument,
						personally came before me and acknowledged that (he)(she) executed the
						same.
______________
Judge of the Court