D.R.L. §§ 111(1)(f), 115(4) Form 2-B
(Agreement of Adoption
Private-Placement)
8/2002
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 ______
AGREEMENT OF
ADOPTION
______(Private-Placement)
______
The under signed petitioning adoptive parent(s) hereby agree(s) to adopt the above-named adoptive child and to treat said child in all respects as (his)(her)(their) own lawful child and to extend and assure to said child all the rights, benefits and privileges incident to such relationship, and to incur and fulfill all the responsibilities of (a) parent(s) with respect to said child.
Dated:______,___.
______/______
Adoptive Parent: typed or printed name/ signature
______/______
Adoptive Parent: typed or printed name / signature
______/______
Adoptive child if over 14: typed or printed name/ signature
______/______
Attorney if any: typed or printed name/signature
______
Attorney’s Address and Telephone number
STATE OF NEW YORK )
ss:
COUNTY______)
On [specify date]: ______, [specify name]:______
personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement of adoption and consent.
______
Notary Public
STATE OF NEW YORK )
ss:
COUNTY______)
On [specify date]:______, [specify name]:______
personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement of adoption and consent.
______
Notary Public
STATE OF NEW YORK )
ss:
COUNTY______)
On this___day of ______,__, ______, proven to me by the oath of ______, an attorney admitted to practice in the State of New York, to be the person(s) who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
______
Judge of the______Court