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 1-B - Verified schedule (agency)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L.; §§ 111-a, 112(3), 112-b
						Adoption Form 1-B
S.S.L. §§ 383-c, 384 (Verified
						Schedule-Agency)
(9/2006)
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
VERIFIED SCHEDULE
(Agency)
________
TO THE COURT:
1. I,, am a duly constituted official
						of
, the authorized agency whose principal
						office is at
, and who has custody of is placing the
						adoptive child named in the caption of this proceeding for adoption.
2. On information and belief, the full
						name, date and place of birth of the adoptive child are:
[Attach certified copy of birth
						certificate]
3a. On information and belief, the full
						name and last known address of the birth mother of the adoptive child
						are:
3b. On information and belief, the full
						name and last known address of the birth father of the adoptive child
						are:
4. This agency obtained custody of the
						adoptive child in the following manner:
5. [Applicable to Interstate Compact on
						Placement of Children cases]: The administrator of the Interstate Compact for
						the Placement of Children of the State of New York or his or her designee, has
						certified that such placement complied with the provisions of the compact. A
						true copy of the signed document is attached and made a part of this
						schedule.
6. [Check applicable box(es)]:
(a) The consent to this adoption by
						[specify]:, birth mother of the adoptive child,
is attached hereto is unnecessary for the
						following reasons [specify]:
Form 1-B Page 2
(b) The consent to this adoption by
						[specify]:, birth father of the adoptive child,
is attached hereto is unnecessary for the
						following reasons [specify]:
6. The birth parent(s) of the adoptive
						child have have not requested this agency to return the adoptive child to the
						birth parent(s) within thirty days of the execution and delivery of an
						instrument of surrender to an authorized agency, except [specify, if
						applicable]:
7. Attached hereto and made a part hereof
						is a document setting forth all available information comprising the adoptive
						child's medical history.
8. [Applicable if there is a Post-adoption
						Contact Agreement; attach true copy]:
On [specify date]:, at the time of the
						approval of the surrender of the child, the Family Court, [specify]: County,
						approved the attached Post-adoption Contact Agreement as being in the child's
						best interests. The agreement was consented to in writing by the following
						[specify]:
Adoptive parent(s)[specify]:
Birth parent(s) [specify]:
Adoptive child's law guardian
						[specify]:
Sibling(s) or half-sibling(s) over the age
						of 14, if contact is with siblings or half-siblings [specify]:
Date:
______________
Authorized Agency
By ________
______________
Title
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone
						Number
Form 1-B Page 3
VERIFICATION
STATE OF NEW YORK)
ss.:
COUNTY OF)
being duly sworn,
deposes and says:
That (he) (she) is a duly constituted
						official of the above-named authorized agency, to wit, its
;
That (he) (she) has read the foregoing
						Schedule and knows the contents thereof; that the same is true to (his) (her)
						own knowledge except as to matters therein stated to be alleged on information
						and belief and that as to those matters (he) (she) believes it to be
						true.
______________
Agency Official
Sworn to before me this day of,.
______________
(Deputy) Clerk of the Court
Notary Public