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 26-a - Affidavit and report (disinterested person-extension of expired certification)
D.R.L. §§ 115, 115-d(9) Form 26-a
(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 (Docket) (File) No.
A Child Whose First Name is
AFFIDAVIT and
REPORT
(Disinterested Person-
Extension of Expired
by Certification)
Adoptive Parent(s)
________
[Name] , being duly sworn, deposes and
says that:
1. I am a disinterested person as defined in section 115-d(4) of the Domestic Relations Law in that (he)(she) has no interest in the outcome of the application of the part(y)(ies) herein for certification as (a) qualified adoptive parent(s).
2. The following fee(s) (have been) (will be) paid to deponent for services rendered in connection with the application for extension of certification:
3. I have read the affidavit and report prepared by
and submitted in support of the petition for certification as (a) qualified adoptive parent(s) submitted by petitioner(s) on , 19 . On information and belief, an order granting certification as a qualified adoptive parent(s) was made by the Court,
County, on , 19 , and expired on , 19 .
4. The following Change(s) in circumstances relevant and material to the extension of such certification (has)(have) taken place since the issuance and expiration of the last certification:
5. The source of my knowledge concerning the circumstances of the petitioner's(s') family and household is: [include date, place and duration of personal interview and visit at petitioner's(s') home.]
Form 26-a page 2
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 .
______________
Notary Public
