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-A - Petition for adoption (agency)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 111-a(1), 112 Form
						1-A
(Adoption
Petition-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
PETITION FOR
ADOPTION
(Agency)
________
The Petitioner(s) respectfully allege(s)
						to this Court that [Delete inapplicable provisions]:
1. Petitioning adoptive parent [specify
						name]:
a. resides at [specify address, including
						county]:
b. is of full age, having been born on
						[specify date of birth]:
c. is unmarried married to [specify name]:
						and living together;
married to [specify name]: and living
						separate and apart pursuant to a decree or judgment of separation or pursuant
						to a separation agreement subscribed by the parties thereto and acknowledged or
						proved in the form required to entitle a deed to be recorded;
married to [specify name]: and living
						separate and apart for at least three years prior to commencement of the
						proceeding);
d. is of the following religious faith, if
						any [specify]:
e. is engaged in the following occupation
						[specify]: and earns $ in approximate annual income [delete if inapplicable]:
						of which $ is support and maintenance to be received from the Commissioner of
						Social Services on behalf of the adoptive child.
2. Petitioning adoptive parent [specify
						name]:
a. resides at [specify address, including
						county]:
b. is of full age, having been born on
						[specify date of birth]:
c. is unmarried married to [specify name]:
						and living together;
married to [specify name]: and living
						separate and apart pursuant to a decree or judgment of separation or pursuant
						to a separation agreement subscribed by the parties thereto and acknowledged or
						proved in the form required to entitle a deed to be recorded;
married to [specify name]: and living
						separate and apart for at least three years prior to commencement of the
						proceeding);
Form 1-A Page 2
d. is of the following religious faith
						[specify]:
e. is engaged in the following occupation
						[specify]:
and earns $ in approximate annual income
						[delete if inapplicable]: of which $
is support and maintenance to be received
						from the Commissioner of Social Services on behalf of the adoptive
						child.
3. Upon information and belief, the
						adoptive child, whose first name is [specify]:
, was born on,, at and the religious faith
						of such child is [specify]:
4. Upon information and belief, there will
						be annexed to this petition a schedule verified by a duly constituted official
						of [specify agency]:, an authorized agency, as required by section
						112
						(3) of the Domestic Relations Law, concerning
						the adoptive child who is the subject of this proceeding.
5. The following is information, as nearly
						as can be ascertained, concerning the birth or legal parents of the adoptive
						child:
(a) Age and date of birth
Parent [specify name]:
Parent [specify name]:
(b) Heritage (specify nationality, ethnic
						background, race)
Parent [specify name]:
Parent [specify name]:
(c) Religious faith, if any
Parent [specify name]:
Parent [specify name]:
(d) Education [specify number of years of
						school or degrees completed at time of birth of adoptive child]:
Parent [specify name]:
Parent [specify name]:
(e) General physical appearance at time of
						birth of adoptive child [specify height,
weight, color of hair, eyes, skin]:
Parent [type name]:
Ht: ________ Wt: ________
Hair Color: ________ Eye Color:
						________
Skin Color: ________
Parent [type name]:
Ht: ________ Wt: ________
Hair Color: ________ Eye Color:
						________
Skin Color: ________
Form 1-A Page 3
(f) Annex Form 1-D which provides health
						and medical history of birth parents at time of birth of adoptive child,
						including conditions or diseases believed to be hereditary and any drugs or
						medication taken during pregnancy by child's mother.
(g) Specify any other information which
						may be a factor influencing the adoptive child's present or future well-being,
						including talents, hobbies and special interests of parents: [attach separate
						sheet if necessary]
6. The subject child is is not a
						Native-American child, who is subject to the Indian Child Welfare Act of 1978
						(25 U.S.C. §§
												1901 -
						1963). If so, the
						following have been notified [check applicable box(es)]:
parent/custodian [specify name and give
						notification date]:
tribe/nation [specify name and give
						notification date]:
United States Secretary of the Interior
						[give notification date]:
7. The manner in which the adoptive
						parent(s) obtained the adoptive child is as follows:
[Delete if inapplicable]: 8. The placement
						is subject to the provisions of section(s) 374-a 382 of the Social Services Law
						and the provisions of such sections have been complied with. The original
						approval signed by the Administrator of the Interstate Compact on the placement
						of Children is attached hereto.
9. The adoptive child resided with the
						adoptive parent(s) from [specify date]:
10. Other persons living in the household
						are [specify names and dates of birth]:
11. The name by which the adoptive child
						is to be known is:
12. Upon information and belief, the
						adoptive child has has not been previously adopted.
13. To the best of Petitioner(s)'
						information and belief, there are no persons other than those mentioned herein
						or in the verified schedule annexed hereto who are entitled, pursuant to
						Sections
						111
						(3) and
						111-a
						of the Domestic Relations Law, to notice of this proceeding (except):
Name: Relationship:
Last known address:
Name: Relationship:
Last known address:
Name Relationship:
Last known address:
14(a). The adoptive parent(s) (has)(have)
						(has)(have) no knowledge that the child or an adoptive parent is the subject of
						an indicated report, or is another person named in an indicated report of child
						abuse or maltreatment, as such terms are defined in section
						412 of the
						Social Services Law, or has been the subject of or the respondent in a child
						protective proceeding which resulted in an order finding that the child is an
						abused or neglected child.
Form 1-A Page 4
(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:
Neither the adoptive parent(s) nor any
						other adult over the age of 18 residing in the household have a criminal
						record.
The following adoptive parent(s)[specify]:
						have been convicted of the following offenses [specify, including dates) of
						conviction]:
However, denial of Petitioner's petition
						will create an unreasonable risk of harm to the physical or mental health of
						the child and granting the petition will not place the child's safety in
						jeopardy and will be in the best interests of the child, pursuant to Social
						Services Law § 378-a(2)(e)(1), for the following reason(s)
						[specify]:
The following adult over the age of 18
						living in the home [specify]:
has the following record of criminal
						conviction(s) [specify, including date(s)]:
15. There are no prior or pending
						proceedings affecting the custody or status of the adoptive child, including
						any proceeding[s] dismissed or withdrawn, (except) [specify type of proceeding,
						court, disposition, if any, and date of disposition, if any]:
[If there is a post-adoption contact
						agreement, attach it and answer Question 16]:
16. On [specify date]:, at the time of the
						approval of the surrender of the child, the Family Court, [specify]: County,
						approved the annexed 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]:
17. This petition has has not been filed
						in the Court that exercised jurisdiction over the most recent permanency or
						other proceeding involving this child. [If it has not, petitioner must file
						affirmation, Adoption Form 1-E].
18. [Insert any additional
						allegations.]
WHEREFORE, the Petitioner(s) requests an
						order:
approving the adoption of the adoptive
						child [specify first name]: by the Petitioner(s), and [delete if inapplicable]:
						incorporating the post-adoption contact agreement, and directing that the
						adoptive child shall be treated in all respects as the child of the
						Petitioner(s), and directing that the name of the adoptive child be changed and
						that (s)he shall henceforth be known by the name of [specify]:, together with
						such other and further relief as may be just and proper.
Dated:,.
Form 1-A Page 5
/
__________________
Adoptive Parent: typed or printed
						name/signature
/
__________________
Adoptive Parent: typed or printed
						name/signature
/
__________________
Adoptive child if over 18: typed or
						printed name/signature[FN1]
/
__________________
Attorney if any: typed or printed
						name/signature
/
__________________
Attorney's Address and Telephone
						number
VERIFICATION
STATE OF NEW YORK)
:ss.:
COUNTY OF)
being duly sworn, says that (he)(she)
						(they)(is)(are) the Petitioner(s) in the above-named proceeding and that the
						foregoing petition is true to (his)(her)(their) own knowledge, except as to
						matters where in stated to be alleged on information and belief and as to those
						matters (he)(she) (they) believe(s) it to be true.
/
______________
Adoptive Parent: typed or printed
						name/signature
/
______________
Adoptive Parent: typed or printed
						name/signature
/
______________
Adoptive child if over 18: typed or
						printed name/signature
Sworn to before me this day of,.
______________
(Deputy) Clerk of the Court
Notary Public
Resworn to before me this day of,.
________
Judge of the Court
[FN1] If the child is over the age of 14,
						written consent to the adoption must also be attached.