Affidavit of Birth Mother [FormDRL 111a]
FAMILY COURT OF THE STATE OF NEW YORK
COUNTY OF QUEENS
____________________________
In the Matter of the Adoption )
by ____________________ ) NATURAL MOTHER'S AFFIDAVIT (DRLs 1111) (Required if adoptive child was born out of wedlock)
of ___________, Adoptive Child. ) Docket No. ________
) [Name of Assigned Judge]
______________________________
STATE OF NEW YORK )
) ss.:
COUNTY OF QUEENS )
______, being duly sworn, deposes and says that:
1. I am the natural mother of ______ born on ______ in New York City, Queens County.
2. No person has ever been judicially adjudicated to be the father of my child.
3. The putative father of said child has never cohabited with myself or my child since the birth of said child.
4. The putative father has never had de facto custody of said child.
5. The putative father has never contributed regularly to the support and maintenance of the child.
6. The putative father has never visited the child nor evidenced an interest in the welfare of the child.
7. The putative father has never asserted any parental rights as to the child.
8. The putative father is recorded as the father of my child on my child's birth certificate.
No person is recorded on my child's birth certificate as the child's father.
9. I have never identified any person as my child's father in a written, sworn statement.
10. I am not now openly living with my child and any person who holds himself out to be the child's father.
11. I was not married to any person within six months subsequent to the birth of my child and prior to the execution of a surrender instrument or the initiation of a proceeding involving the guardianship and custody of my child pursuant to section three hundred eightyfourb of the social services law.
______________________________
Sworn to before me this
______ day of ______, 19___
___________________________
NOTARY PUBLIC
NOTE: Delete any of the above statements which affiant is unable to make and explain circumstances fully in separate affidavit.