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 .
