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 22 - Petition (certification as a qualified adoptive parent) (private- placement)
D.R.L. §§ 115, 115-d Form 22
(Certification
As Qualified
Adoptive Parent)
9/99
________
In the Matter of the Adoption of (Docket) (File) No.
A Child whose First Name is
PETITION
by Adoptive Parent(s) (Certification as a Qualified
Adoptive Parent)
(Private-Placement)
________
The Petitioner(s) respectfully allege(s) to this Court that:
[Delete inapplicable provisions]:
1. (His)(Her)(Their) name(s), residential address and telephone number are:
Petitioner (specify name):
Petitioner (specify name):
2. (He)(She)(They) (is)(are) seeking certification by this court as (a) person(s) qualified to take custody of the adoptive child [specify first name]: , (prior to)
(contemporaneous with) the filing of a private-placement adoption petition.
3. (He)(She)(They) (has)(have) (not) been the subject of a pending child protective investigation or of an indicated report, as such term is defined in section 412 of the Social Services Law, filed with the statewide register of child abuse and maltreatment pursuant to Title six of Article six of the Social Services Law.
4. A pre-placement investigation will be undertaken by a disinterested person, as such term is defined in section four of 115-d of the Domestic Relations Law, and a written report of such investigation will be furnished directly to the court by such disinterested person.
5. The marital, family status and history of the Petitioner(s) (is) (are):
Petitioner (specify name):
Petitioner (specify name):
6. The physical and mental health of the Petitioner(s) (is)(are):
Petitioner (specify name):
Petitioner (specify name):
7. Attached hereto and made a part hereof is a statement of all property owned by and income of the Petitioner(s).
8. Petitioner(s) (has)(have)(not ever been) (a) respondent(s) in any proceeding in a court concerning alleged (abused) (neglected) (abandoned) children, (except as follows):
Form 22 page 2
Petitioner (specify name):
Petitioner (specify name):
(he) (she) executed the same.
Petitioner (specify name):
Petitioner (specify name);
9. Petitioner(s) (has)(have)(not) made any prior application for certification as (a) qualified adoptive parent(s); if so, the disposition and disposition date of such application was as follows:
Petitioner (specify name):
Petitioner (specify name);
);
10. Petitioner(s) (do) (does) (not) intend to cause a pre-placement investigation to be undertaken (and request(s) this court to appoint a disinterested person to conduct such pre-placement investigation;)
WHEREFORE, Petitioner(s) pray(s) for an order (conditionally)[FN2] certifying Petitioner(s) as (a) qualified adoptive parent(s).
/
_________________________
Petitioner: typed or printed name/signature
/
_________________________
Petitioner: typed or printed name/signature
/
_________________________
Attorney: typed or printed name/signature
_________________________
Attorney's Address and Telephone Number
Form 22 Page 3
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 therein stated to be on information and belief as to those matters (he)(she)(they) believe(s) it to be true.
/
_________________________
Petitioner: typed or printed name/signature
/
_________________________
Petitioner: typed or printed name/signature
Sworn to before me this day of , .
______________
(Deputy) Clerk of the Court
Notary Public
[FN1] Fingerprint cards must be provided to the Court so that a criminal history report can be obtained from the N.Y.S. Division of Criminal Justice Services pursuant to Domestic Relations Law Section 115-d(3-a).
[FN2] Applicable only if petition seeks conditional certification pursuant to D.R.L. Section 115-d(6).
