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 27-A - Petition for access to sealed adoption records

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. § 114 Adoption Form
						27-A
(Adoption--Petition for Access to
Sealed Adoption Records)
(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
ACCESS TO SEALED
ADOPTION RECORDS
________
TO THE FAMILY COURT OF THE COUNTY OF
						[specify]:
The Petitioner respectfully alleges to
						this Court that:
1. [Check applicable box]:
I am the child who was adopted in the
						above-entitled proceeding.
My relationship to the above-named child
						is as follows [specify]:
2. a. I reside at [specify address and
						telephone number]:
b. My mailing address, if different from
						the above, is [specify]:
3. Upon information and belief, [check
						applicable box]:
[Applicable where Petitioner is the
						adoptee]: I was born in [specify city, village or town and State]: on or about
						[specify date]: A certified copy of my birth certificate is attached.
[Applicable where Petitioner is not the
						adoptee]: [specify adoptee's name]: was born in [specify city, village or town
						and State]: on or about [specify date]: A certified copy of the birth
						certificate is attached.
4. Upon information and belief, [check
						applicable box]:
[Applicable where Petitioner is the
						adoptee]: I was adopted pursuant to court order in the [specify county and
						court, if known]:
[Applicable where Petitioner is not the
						adoptee]: [specify adoptee's name]: was adopted pursuant to court order in the
						[specify county and court, if known]:
5. A request for information has has not
						been made of the Adoption Information Registry. [Direct inquiries to: NYS
						Department of Health, Adoption Information Registry, P.O. Box 2602, Albany, New
						York 12220-2602, (518)474- 9600]
6. The names, dates of death, permanent
						addresses of the adoptive parents, if living, and the adoptee's birth name, if
						known, are as follows [specify]:
7. [Check applicable box(es)]:
I am requesting access to sealed adoption
						records on medical grounds for the following
Adoption Form 27-A Page 2
reasons [specify]:
[NOTE: If your request is based on medical
						grounds, you must attach a medical certification from a physician licensed to
						practice medicine in the State of New York addressing a serious physical or
						mental illness. Such certification shall identify the information required to
						address the illness.]
I am requesting access to sealed adoption
						records for good cause, other than medical, for the following reasons
						[specify]:
[Applicable to Native-American individuals
						18 years of age and older]: I am requesting access to sealed adoption records,
						including information about my birth parents' tribal affiliation(s), if any,
						and other information necessary to protect any rights flowing from such tribal
						affiliations.
8. No previous application has been made
						for the relief requested herein except as follows: [Enter "NONE", or
						specify]:
I understand that the Court may appoint a
						law guardian for the purpose of reviewing the file and determining whether the
						information being sought is in the file and to undertake such other and further
						instructions that the Court may require.
WHEREFORE, for the reasons stated above, I
						respectfully request access to the sealed adoption records and information
						sought above and for such other and further relief as this Court deems just and
						proper.
Dated:,.
______________
Petitioner's signature
______________
Petitioner: Print or type name
______________
Attorney' signature, if any
________
______________
Attorney's Address and Telephone
						number
VERIFICATION
STATE OF NEW YORK)
:ss.:
COUNTY OF)
being duly sworn, says that (he)(she) is
						the Petitioner(s) in the above-named proceeding and that the foregoing petition
						is true to (his)(her) own knowledge, except as to matters stated to be alleged
						on information and belief and as to those matters (he)(she) believe(s) them to
						be true.
/
_________________________
Petitioner: typed or printed name/
						Signature
Sworn to before me this day of,.
______________
(Deputy) Clerk of the Court
Notary Public