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-B - Verified schedule (agency)
D.R.L. §§ 111-a, 112(3) Form 1-B
S.S.L. § 384 (Verified Schedule-
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
VERIFIED SCHEDULE
(Agency)
________
TO THE COURT:
1. I,, am a duly constituted official of
, the authorized agency whose principal office is at
, and who (has custody of) (is placing) the adoptive child named in the caption of this proceeding for adoption.
2. On information and belief, the full name, date and place of birth of the adoptive child are:
[Attach certified copy of birth certificate]
3a. On information and belief, the full name and last known address of the natural mother of the adoptive child are:
3b. On information and belief, the full name and last known address of the natural father of the adoptive child are:
4. This agency obtained custody of the adoptive child in the following manner:
[FN*] (and attached hereto is a copy of the document signed by the administrator of the interstate compact for the placement of children of the State of New York or his designee, that such placement complied with the provisions of the compact.)
Form 1-B page 2
5. [FN**] (a) The consent to this adoption by, natural
mother of the adoptive child, (is attached hereto) (is unnecessary for the following reasons:)
**(b) The consent to this adoption by ,
natural father of the adoptive child, (is attached hereto) (is unnecessary for the following reasons:)
6. The natural parent(s) of the adoptive child (has) (have) not requested this agency to return the adoptive child to the natural parent(s) within thirty days of the execution and delivery of an instrument of surrender to an authorized agency (except)
7. Attached hereto and made a part hereof is a document setting forth all available information comprising the adoptive child's medical history.
Date:
______________
Authorized Agency
By ________
______________
Title
______________
Petitioner
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone Number
Form 1-B page 3
VERIFICATION
STATE OF NEW YORK)
ss.:
COUNTY OF)
being duly sworn,
deposes and says:
That (he) (she) is a duly constituted official of the above-named authorized agency, to wit, its
;
That (he) (she) has read the foregoing Schedule and knows the contents thereof; that the same is true to (his) (her) own knowledge except as to matters therein stated to be alleged on information and belief and that as to those matters (he) (she) believes it to be true.
______________
Agency Official
Sworn to before me this day of, 19.
______________
(Deputy) Clerk of the Court
Notary Public
[FN*] See D.R.L. Sec. 112(3); delete if inapplicable.
[FN**] Omit if inapplicable
