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-Ga - Extrajudicial consent (birth or legal parent - private-placement - step-parent)
D.R.L. §§ 115, 115-b(8) Form 2-Ga
(Extrajudicial Consent
Birth or Legal Parent -
Private-Placement
Step-parent)
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-
Step-parent)
________
1. I, , residing at
, am the (birth) (legal) parent of . I do hereby consent to the adoption of my (daughter)(son)
, born on
by[specify name]: , adoptive parent.
2. the name and last known address of the other (birth)(legal) parent of the adoptive child are:[FN1]
Dated: ________
/
_________________________
(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-ga page 2
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
[FN1] Delete if inapplicable
