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-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)
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
(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;
(I) [FN3] ( ____________ and I jointly and
						severally) undertake that defendant will appear in
(I) [FN3] ( ____________ and I jointly and
						severally) undertake that defendant will appear in
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).
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;
(I) [FN3] ( ____________ and I jointly and
						severally) undertake that defendant will appear in
Form 1-A page 2
(I) [FN3] ( ____________ and I jointly and
						severally) undertake that defendant will appear in
d. is of the following religious
						faith:
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. Upon information and belief, the
						adoptive child, whose first name is, was born on, 19, at and the religious
						faith of such child
is.
4. Upon information and belief, there will
						be annexed to this petition a schedule verified by a duly constituted official
						of, 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 (height, weight, color of hair, eyes, skin)
Parent (type name):
Ht: ________ Wt:________
Hair Color:________ Eye Color:
						________
Skin Color:________
Form 1-A page 3
Parent (type name):
Ht: ________ Wt:________
Hair Color:________ Eye Color:
						________
Skin Color:________
(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) 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 adoptive child (is) (is not) an
						Indian child within the meaning of the Indian Child Welfare Act of 1978 ( 225
						U.S.C. §§ 1901 - 1963).
7. The manner in which the adoptive
						parent(s) obtained the adoptive child is as follows:
(I) [FN3] ( ____________ and I jointly and
						severally) undertake that defendant will appear in
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:
Form 1-A page 4
Name: Relationship:
Last known address:
14(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)
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]:
16. [Insert any additional
						allegations.]
WHEREFORE, the Petitioner(s) pray(s) for
						an order approving 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-A Page 5
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