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 9-A - Affidavit of financial disclosure - parents (agency)

Universal Citation: 22 NY Comp Codes Rules and Regs ยง 9-A
Current through Register Vol. 46, No. 12, March 20, 2024

S.S.L. § 374(6); Form 9-A

22 NYCRR 207.55(b)(8) (Affidavit of Financial

Disclosure - Parents

- Agency)

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 OF

FINANCIAL

DISCLOSURE -

PARENTS

(Agency)

________

STATE OF NEW YORK )

ss:

COUNTY OF )

(and )

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

1. That deponent(s) reside(s) at

and (is) (are)

the (petitioning adoptive parent(s)) (birth or legal parent(s)) of the above-named adoptive child; and

2. That deponent(s) (has) (have) paid or given or caused to be paid or given or undertaken to pay or give the following expenses, contributions, compensation or things of value, either directly or indirectly, to any person, agency, association, corporation, institution, society or organization, in connection with the placing out of said adoptive child with deponent(s) or with the adoption of said child by deponent(s):

[Specify recipient, amount, form, and purpose of each payment. If none, so state.]

;

3. That deponent(s) (has) (have) requested, received or accepted, either directly or indirectly, the following compensation or things or value from any person, agency, association, corporation, institution, society or other organization in connection with the placing out of said adoptive child with

Form 9-A page 2

deponent(s) or with the adoption of said child by deponent(s).

[Specify source, amount, form

and purpose of each payment

requested or received. If none,

so state.]

/

[FN ]

_________________________

*(Adoptive)(Birth)(Legal) Parent: typed or printed name/signature

/

_________________________

*(Adoptive)(Birth)(Legal) Parent: typed or printed name/signature

/

_________________________

Adoptive child if over 18: typed or printed name/signature

/

_________________________

Attorney if any: typed or printed name/signature

_________________________

Attorney's Address and Telephone number

Sworn to before me this day of , 19 .

________

Judge of the Court

[FN ] Delete inapplicable provisions

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