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-E - Affidavit (change of circumstances since certification as qualified adoptive parent)

Current through Register Vol. 46, No. 12, March 20, 2024

D.R.L. § 115-c Form 21-E

S.C.P.A. § 1725 (Temporary

Guardianship)

12/97

SURROGATE'S COURT OF THE STATE OF NEW YORK

COUNTY OF

________

In the Matter of the Temporary (Docket)(File) No.

Guardianship of A Child Whose

First Name is AFFIDAVIT

(Change of circumstance

since certification as qualified

adoptive parent)

________

STATE OF NEW YORK )

) ss.:

COUNTY OF )

, being duly sworn depose(s) and say(s):

1. Deponent(s) (was)(were) certified as (a) qualified adoptive parent(s) by order of the

Court, County of , dated , 19 ;

2. The following change(s) in circumstance relevant and material to such certification (has)(have) taken place since that date:

Dated:

______________

Petitioner

______________

Print or type name

______________

Signature of Attorney, if any

______________

Attorney's Name (Print or Type)

________

________

______________

Attorney's Address and Telephone Number

Sworn to before me this day of , 19 .