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 23 - Affidavit and report (disinterested person certification proceeding) (private placement)
D.R.L. §§ 115, 115-d Form 23
(Certification
as Qualified
Adoptive Parent)
12/97
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________
In the Matter of the Adoption of
A Child Whose First Name Is (Docket)(File) No.
AFFIDAVIT and
REPORT (Disinterested
Person-Certification
by Proceeding)
Adoptive Parent (Private-Placement)
________
State of New York)
) ss.:
County of)
being duly sworn deposes and says that:
1. (He)(She) is a disinterested person as such person is defined in section 115-d of the Domestic Relations Law in that:
and has no interest in the outcome of the application of the part(y)(ies) herein for certification as qualified adoptive parent(s);
2. The following fee(s) (have been) (will be) paid to deponent for services rendered in connection with the pre-placement investigation performed in connection with this certification proceeding:
;
3. The following is deponent's report of (his)(her) investigation into the truth and accuracy of the allegations set forth in the petition of, as qualified adoptive parents in the proceeding for certification and (deponent's investigation of the various factors relevant to the suitability of the petitioners as qualified adoptive parents:
Form 23 page 2
(a) Date, place and duration of personal interview and visit at petitioners home:
(b) Report:
(iv), CPLR 315 (Order of Publication
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.
