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-B - Verified schedule (agency)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. §§ 111-a, 112(3) Form
						1-B
S.S.L. § 384 (Verified
						Schedule-
Agency)
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
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 natural mother of the adoptive child
						are:
3b. On information and belief, the full
						name and last known address of the natural father of the adoptive child
						are:
4. This agency obtained custody of the
						adoptive child in the following manner:
[FN*] (and attached hereto is a copy of
						the document signed by the administrator of the interstate compact for the
						placement of children of the State of New York or his designee, that such
						placement complied with the provisions of the compact.)
Form 1-B page 2
5. [FN**] (a) The consent to this adoption
						by, natural
mother of the adoptive child, (is attached
						hereto) (is unnecessary for the following reasons:)
**(b) The consent to this adoption by
						,
natural father of the adoptive child, (is
						attached hereto) (is unnecessary for the following reasons:)
6. The natural parent(s) of the adoptive
						child (has) (have) not requested this agency to return the adoptive child to
						the natural parent(s) within thirty days of the execution and delivery of an
						instrument of surrender to an authorized agency (except)
7. Attached hereto and made a part hereof
						is a document setting forth all available information comprising the adoptive
						child's medical history.
Date:
______________
Authorized Agency
By ________
______________
Title
______________
Petitioner
______________
Print or type name
______________
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, 19.
______________
(Deputy) Clerk of the Court
Notary Public
[FN*] See D.R.L. Sec. 112(3); delete if
						inapplicable.
[FN**] Omit if
						inapplicable