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 21-A - Petition for temporary guardianship
D.R.L. § 115-c; S.C.P.A. § 1725
Form 21-A
(Temporary
Guardianship)
12/97
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________
In the Matter of the Temporary
Guardianship of a Child Whose (Docket) (File) No.
First Name is
Petition for Temporary
Guardianship
________
The Petitioner(s) respectfully allege(s) to the Court that:
1. Physical custody of (first name) (last name)
, a child born on , was transferred to and , for the purposes of adoption on the day of , 19 , by , the child's (parent(s))(guardian(s)), (and requirements for certification of as, qualified adoptive parents herein was duly waived by order of the Court, County of dated
2. The residence and telephone number of Petitioner(s) is
3. The full name(s) and address(es) of the natural parent(s) of the child are:
.
4. The anticipated name of the child subsequent to adoption will be
.
5. The anticipated residence of the child subsequent to adoption will be
.
Form 21-A page 2
6. A consent to the adoption of the child was duly executed pursuant to section 115-b of the Domestic Relations Law on , 19 . A copy of the consent to the adoption is annexed hereto.
7. The child will be residing with Petitioner(s), and a petition for adoption of the child by Petitioner(s) will be filed in the Court of the County of , State of New York, within 45 days of the execution of the consent to adoption of the child.
8. No previous petition has been filed or application made to any court or judge for the relief sought herein (except) [include any proceedings dismissed or withdrawn]
WHEREFORE, Petitioner(s) pray(s) for an order granting temporary guardianship of the child to Petitioner(s).
______________
Petitioner(s)
________
______________
Applicant
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone Number
Dated: 19
Form 21-A page 3
VERIFICATION
STATE OF NEW YORK )
) ss.:
COUNTY OF )
, being duly sworn, says that (he) (she) (they) (is)(are) the Petitioner(s) in the above-named proceeding and that the foregoing petition is true to (his) (her) (their) own knowledge, except as to matters therein stated to be alleged on information and belief, and as to those matters (he)(she)(they) believe(s) it to be true.
______________
Petitioner(s)
Subscribed and sworn to before me this day of , 19 .
______________
(Deputy) Clerk of the Court
Notary Public
