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-E - Affidavit and consent of person having lawful custody (other than birth or legal parent - private-placement)
D.R.L. §§ 109(6), 111(1) (f), Form 2-E
115(6) (Affidavit and Consent
- Person Having Custody
Private-Placement)
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
AFFIDAVIT AND
CONSENT
OF PERSON HAVING
LAWFUL CUSTODY
(Other than Birth
or Legal Parent-
Private-Placement)
________
STATE OF NEW YORK )
ss.:
COUNTY OF )
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
being duly sworn, depose(s) and say(s):
Deponent(s) reside(s) at
and (is)(are) the person(s) having lawful custody of the above-named adoptive child in that:
[recite facts showing how lawful custody was obtained]
Deponent(s) hereby consent(s) to said child's adoption by the petitioning adoptive parent(s) (and ).
________
________
Form 2-E page 2
/
_________________________
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
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 to me 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 to me that (he)(she) executed the same.
______________
Notary Public
