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-G - Extrajudicial consent (birth or legal parent - private-placement)
D.R.L. §§ 115, 115-b Form 2-G
(Extrajudicial Consent -
Birth or Legal Parent --
Private-placement)
12/97
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
EXTRAJUDICIAL CONSENT
(Birth or Legal Parent--
Private Placement)
________
THIS CONSENT MAY BE REVOKED WITHIN 45 DAYS OF THE EXECUTION OF THIS DOCUMENT. IF THE CONSENT IS NOT REVOKED WITHIN SAID 45 DAYS, NO PROCEEDING MAY BE MAINTAINED BY THE PARENT FOR THE RETURN OF THE CUSTODY OF THE CHILD. THE REVOCATION MUST BE IN WRITING AND RECEIVED BY THE COURT WHERE THE ADOPTION PROCEEDING IS TO BE COMMENCED WITHIN 45 DAYS OF THE EXECUTION OF THE CONSENT. THE NAME AND ADDRESS OF THE COURT IN WHICH THE ADOPTION PROCEEDING HAS BEEN OR IS TO BE COMMENCED IS
.
IF THE ADOPTIVE PARENTS CONTEST THE REVOCATION, TIMELY NOTICE OF REVOCATION WILL NOT NECESSARILY RESULT IN THE RETURN OF THE CHILD TO THE PARENT, AND THE RIGHT OF THE PARENT TO THE CUSTODY OF THE CHILD WILL NOT BE SUPERIOR TO THOSE OF THE ADOPTIVE PARENTS. A HEARING BEFORE A JUDGE WILL BE REQUIRED TO DETERMINE: (1) WHETHER THE NOTICE OF REVOCATION WAS TIMELY AND PROPERLY GIVEN; AND IF NECESSARY, (2) WHETHER THE BEST INTERESTS OF THE CHILD WILL BE SERVED: (A) BY RETURNING CUSTODY OF THE CHILD TO THE PARENT; OR (B) BY CONTINUING THE ADOPTION PROCEEDING COMMENCED BY THE ADOPTIVE PARENTS; OR (C) BY DISPOSITION OTHER THAN ADOPTION BY THE ADOPTIVE PARENTS; OR (D) BY PLACEMENT OF THE CHILD WITH AN AUTHORIZED AGENCY. IF ANY SUCH DETERMINATION IS MADE, THE COURT WILL MAKE SUCH DISPOSITION OF THE CUSTODY OF THE CHILD AS WILL BEST SERVE THE INTERESTS OF THE CHILD.
Form 2-G Page 2
THE PARENT HAS THE RIGHT TO LEGAL REPRESENTATION OF THE PARENT'S OWN CHOOSING, THE RIGHT TO SUPPORTIVE COUNSELING AND MAY HAVE THE RIGHT TO HAVE THE COURT APPOINT AN ATTORNEY 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.
1. I [specify name]:
, residing at
, (birth) (legal) parent of [specify first
name of child]: do hereby consent to the adoption of my
(daughter) (son) who was, born on [specify date]: ,
(by [specify name]:
, adoptive parent(s)).
2. The full name and last known address of the other (birth) (legal) parent of the adoptive child are:
3. I have (not) been represented by counsel. (If represented, state counsel's name, address and telephone number:
.)
Date:
/
_________________________
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
/
_________________________
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-g Page 3
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) acknowledged that (he) (she) executed the same.
______________
Notary Public
