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 22 - Petition (certification as a qualified adoptive parent) (private-placement)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 115, 115-d Form
						22
(Certification
as Qualified
Adoptive Parent)
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
by Adoptive Parent(s)
						(Certification
as a Qualified
Adoptive Parent)
(Private-Placement)
________
The Petitioner(s) respectfully allege(s)
						to this Court that:
[Delete inapplicable provisions]:
1. (His)(Her)(Their) name(s), residential
						address and telephone number are:
Petitioner (specify name):
Petitioner (specify name):
2. (He)(She)(They) (is)(are) seeking
						certification by this court as (a) person(s) qualified to take custody of the
						adoptive child, [specify first name]:, (prior to)
(contemporaneous with) the filing of a
						private-placement adoption petition.
3. (He)(She)(They) (has)(have) (not) been
						the subject of a pending child protective investigation or of an indicated
						report, as such term is defined in section
						412 of the
						Social Services Law, filed with the statewide register of child abuse and
						maltreatment pursuant to Title six of Article six of the Social Services
						Law.
4. A pre-placement investigation will be
						undertaken by a disinterested person, as such term is defined in section four
						of 115-d of the Domestic Relations Law and a written report of such
						investigation will be furnished directly to the court by such disinterested
						person.
5. The marital, family status and history
						of the Petitioner(s) (is) (are):
Petitioner (specify name):
Petitioner (specify name):
6. The physical and mental health of the
						Petitioner(s) (is)(are):
Petitioner (specify name):
Petitioner (specify name):
7. Attached hereto and made a part hereof
						is a statement of all property owned by and income of the Petitioner(s).
8 Petitioner(s) (has)(have)(not ever been)
						(a) respondent(s) in any proceeding in a court concerning alleged (abused)
						(neglected) (abandoned) children, (except as follows:)
Form 22 page 2
Petitioner (specify name):
Petitioner (specify name):
(iv), CPLR 315 (Order of
						Publication
Petitioner (specify name):
Petitioner (specify name);
9. Petitioner(s) (has)(have)(not) made any
						prior application for certification as (a) qualified adoptive parent(s); if so,
						the disposition and disposition date of such application was as follows:
Petitioner (specify name):
Petitioner (specify name);
);
10. Petitioner(s) (do) (does) (not) intend
						to cause a pre-placement investigation to be undertaken (and request(s) this
						court to appoint a disinterested person to conduct such pre-placement
						investigation;)
WHEREFORE, Petitioner(s) pray(s) for an
						order (conditionally)[FN1] certifying Petitioner(s) as (a) qualified adoptive
						parent(s).
/
_________________________
Petitioner: typed or printed
						name/signature
/
_________________________
Petitioner: typed or printed
						name/signature
/
_________________________
Attorney if any: typed or printed
						name/signature
_________________________
Attorney's Address and Telephone
						Number
Form 22 Page 3
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 (he)(she)(they) believe(s) it to be true.
/
_________________________
Adoptive Parent: typed or printed
						name/signature
/
_________________________
Adoptive Parent: typed or printed
						name/signature
Sworn to before me this day of, 19.
______________
(Deputy) Clerk of the Court
Notary Public
[FN1] Applicable only if petition seeks
						conditional certification pursuant to D.R.L. Section
						115-d(6).