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-F - Judicial consent (birth or legal parent - private-placement)
D.R.L. §§ 115, 115-b Form 2-F
(Judicial Consent -
Birth or Legal Parent -
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
JUDICIAL CONSENT
(Birth or Legal Parent
--Private-Placement)
________
THIS CONSENT BECOMES IRREVOCABLE UPON EXECUTION OR ACKNOWLEDGMENT BEFORE ANY JUDGE OR SURROGATE IN NEW YORK STATE OR A COURT OF COMPETENT JURISDICTION IN ANOTHER STATE HAVING JURISDICTION OVER ADOPTION PROCEEDING(S). NO ACTION OR PROCEEDING FOR THE CUSTODY OF THE ADOPTIVE CHILD MAY BE MAINTAINED BY THE PARENT EXECUTING OR ACKNOWLEDGING THE WITHIN CONSENT.
1. I, [specify name]: , residing at , (birth)(legal)
parent of [specify first name]:
, do hereby consent to the adoption of my (daughter) (son) who was born on [specify date]: [FN*] (by [specify name(s)]: , adoptive parent(s)).
2. I have been advised that this consent becomes irrevocable when executed or acknowledged before a judge or surrogate, and thereafter no action or proceeding may be maintained by me for the custody of the child. I also have been advised that before I acknowledge or execute this consent, I have a right to be represented by a lawyer of my own choosing and, if I am financially unable to obtain same, a lawyer will be assigned at public cost. I further have been advised that I have a right to obtain supportive counseling.
3. The full name and last known address of the other (birth) (legal) parent of the adoptive child are:
Dated: Signature:
Form 2-F 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 )
ss.:
County of )
On this day of 19 ,
, the person who executed the foregoing instrument, personally came before me and (he)(she) acknowledged that (he)(she) executed the same. I have informed such person of the consequences of the act of execution and acknowledgment pursuant to the provisions of section 115-b of the Domestic Relations Law and have informed (him)(her) of the right to be represented by legal counsel of (his)(her) own choosing; of the right to obtain supportive counseling and of any rights to assigned counsel pursuant to section 262 of the Family Court Act, section 407 of the Surrogate's Court Procedure Act, or section 35 of the Judiciary Law. I have given (him)(her) a copy of this consent upon execution thereof.
________
Judge of the Court
(Seal of Court to be
affixed together
with Court Clerk's
certification)
[FN*] Optional
