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 1-C - Petition (private-placement)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 111, 111-a, 112, 115
						Form 1-C
S.C.P.A. § 1725(1)
						(Petition-Private-
Placement)
12/97
SURROGATE'S 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
(Private-Placement)
________
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:
e. is engaged in the following occupation
						[specify]: and earns $ (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]:
Form 1-C page 2
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:
e. is engaged in the following occupation
						[specify]: and earns $ in approximate annual income (of which $ is support and
						maintenance to be received from the Commissioner of Social Services on behalf
						of the adoptive child).
3. The full name, date and place of birth
						of the adoptive child is
[attach certified copy of birth
						certificate]
4. Upon information and belief the
						religious faith of the adoptive child, if any,
is.
5. The following is information, as nearly
						as can be ascertained, concerning the birth or legal parents of the adoptive
						child:
(a) Full name and last known
						address
Parent (specify full name and address, if
						known):
Parent (specify full name and address, if
						known):
Form 1-C page 3
(b) Age and date of birth
Parent (specify name):
Parent (specify name):
(c) Heritage (specify nationality, ethnic
						background, race)
Parent (specify name):
Parent (specify name):
(d) Religious faith, if any
Parent (specify name):
Parent (specify name):
(e) Education (specify number of years of
						school or degrees completed at time of birth of adoptive child)
Parent (specify name): ________
Parent (specify name):________
(f) General physical appearance at time of
						birth of adoptive child (height, weight, color of hair, eyes, skin)
Parent (specify name):
Ht: ________ Wt: ________
Hair Color: ________ Eye Color:
						________
Skin Color: ________
Parent (specify name):
Ht: ________ Wt: ________
Hair Color: ________ Eye Color:
						________
Skin Color: ________
(g) Annex Form 1-D which provides health
						and medical history 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.
(h) 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 manner in which the adoptive
						parent(s) obtained the adoptive child is as follows:
7. The adoptive child resided with the
						adoptive parent(s) from [indicate date]:
8. Other persons living in the household
						are: [Specify names and dates of birth]:
Form 1-C page 4
9. The name by which the adoptive child is
						to be known is:
10. Upon information and belief, the
						adoptive child (has) (has not) been previously adopted.
11. The full name(s) and address(es) of
						any person(s) having lawful custody of the adoptive child, if known (is)
						(are)
12. On information and belief, pursuant to
						Domestic Relations Law § 111,
(a) the consent of the birth or legal
						parent of the adoptive child (is attached hereto) (is not required
						because
;)
(b) the consent of the birth or legal
						parent of the adoptive child (is attached hereto) (is not required
						because
;)
(c) the consent(s) of the above-named
						person(s) having lawful custody of the adoptive child (is attached hereto) (is
						not required because
;)
(d) The consent(s) of other person(s)
						[specify names]:
(is attached hereto) (is not required
						because
.)
13(a) (The consent of the birth or legal
						parent [specify name]: was executed
pursuant to section
						115-b
						(3) of the Domestic Relations Law on
________, 19 ________; the 45th day after
						execution of the consent is ________, 19________.
(b) (The consent of the birth or legal
						parent [specify name]: was
executed pursuant to Section
						115-b
						(3) of the Domestic Relations Law on
________, 19________; the 45th day after
						execution of the consent is ____________,
19________.)
(14. This court is not the court named in
						the consent(s) of the parent(s) of the adoptive child, attached hereto, as the
						court in which the adoption proceeding will be commenced, but more than 45 days
						have elapsed since the date of execution of said consent(s) and, on information
						and belief, no written notice of revocation has been received by that
						court.)
(15. That on information and belief said
						minor child has a (general) (testamentary) guardian.
Form 1-C page 5
[state nature, date and place of
						appointment] :
16. To the best of the Petitioner(s)'
						information and belief, there are no persons other than those mentioned herein
						or in the verified scheduled annexed hereto who are entitled, pursuant to
						Domestic Relation Law § 111(3), 111- a, to notice of this proceeding
						(except)
Name: Relationship:
Last known address:
Name: Relationship:
Last known address:
Name: Relationship:
Last known address:
17. Attached hereto and made a part hereof
						is Form 1-D setting forth all available information comprising the adoptive
						child's medical history.
18. The placement is subject to the
						provisions of Social Services Law section(s) (374-a) (382) and the provisions
						of such section(s) have been complied with. The original approval signed by the
						Administrator of the Interstate Compact on the Placement of Children is
						attached hereto.
19. (a) The adoptive parent(s) (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.
(b) The adoptive parent(s) (has) (have)
						(no) knowledge of any criminal record concerning themselves or any other adult
						residing in the household (except)
.
20. There are no prior or pending
						proceedings affecting the custody or status of the adoptive child, including
						any proceedings dismissed or withdrawn, (except) [specify type of proceeding,
						court, disposition, if any, and date of disposition, if any]:
21. The adoptive child (is) (is not) an
						Indian child within the meaning of the Indian Child Welfare Act of 1978
						(25 U.S.C. §§
												1901 -
						1963).
22. [Insert any additional
						allegations.]
Form 1-C page 6
WHEREFORE, the Petitioner(s) pray(s) for
						an order approving granting temporary guardianship of the child to
						Petitioner(s) and the adoption of the adoptive child [specify first
						name]:
by the Petitioner(s) 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
together with such other and further
						relief as may be just and proper.
Dated:, 19.
/
_________________________
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 1-C page 7
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, 19.
______________
(Deputy) Clerk of the Court
Notary Public
Resworn to before me this day of,
						19.
______________
Judge of the Court