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 2-A - Agreement of adoption and consent (agency)
D.R.L. §§ 111(1)(f), 112(2)(b), Form 2-A
113 (Agreement of Adoption
and Consent --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
AGREEMENT OF
ADOPTION AND
CONSENT (Agency)
________
The undersigned petitioning adoptive parent(s) hereby agree(s) to adopt the above-named adoptive child and to treat said child in all respects as (his) (her) (their) own lawful child and to extend and assure to said child all the rights, benefits and privileges incident to such relationship, and to incur and fulfill all the responsibilities of (a) (parent) (parents) with respect to said child.
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
Form 2-A Page 2
The undersigned authorized agency hereby consents to the adoption of the above-named adoptive child by the petitioning adoptive parent(s).
Name of Authorized Agency: ________
By: ________
______________
Title
STATE OF NEW YORK )
ss:
COUNTY OF )
On this day of , 19 , , the person who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
______________
Notary Public
STATE OF NEW YORK )
ss:
COUNTY OF )
On this day of , 19 , , the person who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
______________
Notary Public
Form 2-A Page 3
STATE OF NEW YORK )
ss:
COUNTY OF )
On this day of , 19 , before me personally came , to me known and who by me being duly sworn did depose and say:
That he/she resides at
County of State of :
that he/she is [specify position]:
of [specify authorized agency]:
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
______________
Notary Public
State of New York )
ss:
County of )
On this day of , 19 ,
, proven to me by the oath of
an attorney admitted to practic in the State of New York, to be the person who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
______________
Judge of the Court
