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 1-C - Petition (private-placement)

Universal Citation: 22 NY Comp Codes Rules and Regs § 1-C

Current through Register Vol. 46, No. 12, March 20, 2024

D.R.L. §§ 111, 111-a, 112, 115 Form 1-C

S.C.P.A. § 1725(1) (Petition-Private-

Placement)

9/2006

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

________

In the Matter of 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

(d) . Upon information and belief, an Order of Protection or Temporary Order of Protection (has)(has not) been issued against any of the above adults in any criminal, matrimonial or Family Court proceeding(s). If such an order has been issued, specify the adult against whom the order was issued, the court that issued the order, docket number, date of order, expiration date of order, next court date and status of case to the extent known:

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

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):

(b) Age and date of birth

Form 1-C page 3

Parent (specify name):

(d) Religious faith, if any

Parent (specify name):

(e) Education (specify number of years of school or degrees completed at time of birth of adoptive child)

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]:

9. The name by which the adoptive child is to be known is:

Form 1-C Page 4

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

;)

(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

________, ________; the 45th day after execution of the consent is ________, ________.

(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

________, ________; the 45th day after execution of the consent is ____________,

________.)

(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.

[state nature, date and place of appointment] :

Form 1-C Page 5

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) and 111-a, to notice of this proceeding (except)

Name: Relationship:

Last known address:

Name Relationship:

Last known address:

Name Relationship:

Last known address:

17. The child is is not under the jurisdiction of the Family Court. If so, this petition has has not been filed in the Court that exercised jurisdiction over the most recent permanency or other proceeding involving this child. [If it has not been so filed, petitioner must file affirmation, Adoption Form 1-E].

18. Attached hereto and made a part hereof is Form 1-D setting forth all available information comprising the adoptive child's medical history.

19. 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.

20. (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.

21. 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]:

22. 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 ).

23. [Insert any additional allegations.]

Form 1-C Page 6

WHEREFORE, the Petitioner(s) prays(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: , .

_________________________

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

[FN]

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 , .

______________

Notary Public

Resworn to before me this day of , .

______________

Judge of the Court

[FN] *Note: Consent of a child over 14 must be attached.

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