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 10-B - Supplemental affidavit (private-placement)
22 NYCRR 205.53(c) Form 10-B
(Supplemental Affidavit-
Private-Placement)
9/99
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
SUPPLEMENTAL
AFFIDAVIT
(Private-Placement)
________
STATE OF NEW YORK )
ss:
COUNTY OF )
(and )
being duly sworn, depose(s) and say(s):
1. Deponent(s) (is) (are) the same person(s) who on filed in this Court a petition for adoption of the above-named adoptive child.
2. Deponent(s) (is)(are) over the age of twenty-one years, citizen(s) of the United States, and (unmarried)(married and living together) (married and living apart).
3. The post-office addresses, place(s) of residence and home telephone number(s) of petitioner(s) (is)(are)
Petitioner (specify name):
Petitioner (specify name):
4. Petitioner(s) hereby state(s) that there has been no change of circumstances whatsoever since the filing of said original petition, dated , except as follows:
Form 10-B Page 2
Date:
/
_________________________
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
Sworn to before me this day of , .
______________
Judge of the Court
