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)
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
