Petition for Adoption Private Placement, Based on Official Form [FormDRL 111, 111a, 112, 115; SCPA 1725]
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
.................................................... (Docket) (File) No. ________
)
In the Matter of the Adoption of ) PETITION FOR ADOPTION
A Child Whose Name Is ) (PrivatePlacement)
)
JANE DOE )
-------------------------------------
The Petitioner(s) respectfully allege(s) to this Court that:
1. Petitioning adoptive parent [specify name ]:
JOHN DOE
_________________________________________________________________
a. resides at [specify address, including county ]:
1500 METROPOLITAN AVENUE, #11, BRONX, NY 10462
_______________________________________________________________
b.is of full age, having been born on [specify date of birth ]: MAY 4, 1962
c. is * (unmarried)
*(married to [specify name ]: _____________________
and living together)
*(married to [specify name ]: __________________and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded);
and living separate and apart for at least three years prior to commencement of the proceeding);
d. is of the following religious faith, if any:
AETHEIST
_________________________________________________________________
Form 1C page 2
e. is engaged in the following occupation [specify ]:BUS DRIVER and earns $45,000 PLUS OT (of which $______ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child).
2. *Petitioning adoptive parent [specify name ]:
_________________________________________________________________
a. resides at [specify address, including county ]:
____________________________________________________________________________________________________________________________________________________________
b.is of full age, having been born on [specify date of birth ]: ______, 20___
c. is *(unmarried)
*(married to [specify name ]: ______ and living together)
*(married to [specify name ]: ______ and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded);
and living separate and apart for at least three years prior to commencement of the proceeding);
d. is of the following religious faith, if any:
________________________________________________________________
e. is engaged in the following occupation [specify ]: ______ and earns $______ in approximate annual income (of which $______ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child).
3. The full name, date and place of birth of the adoptive child is JANE DOE, 6-25-01, BRONX, NY
[attach certified copy of birth certificate ]
________________________________________________________________________________________________
Form 1C page 3
4. Upon information and belief, the religious faith of the adoptive child, if any, is CATHOLIC _________________________________________________________________
5. The following is information, as nearly as can be ascertained, concerning the birth parents of the adoptive child:
(a) Full name and last known address
Parent (specify full name and address, if known):
JANEY DOE-MOTHER 1500 METROPOLITAN AVENUE, #10, BRONX, NY 10462
Parent (specify full name and address, if known):
JOHN DOE-FATHER ADDRESS UNKNOWN
(b) Age and date of birth ___________________________________________________
Parent (specify name):JANEY DOE-MOTHER: 5-2-73 _______________________________________________________
Parent (specify name): JOE DOE-FATHER:UNKNOWN _______________________________________________________
(c) Heritage (specify nationality, ethnic background, race)
Parent (specify name): JANEY--PUERTO RICAN _______________________________________________________
Parent (specify name: JOE--PUERTO RICAN _______________________________________________________
(d) Religious faith, if any
Parent (specify name): JANEY--CATHOLIC _______________________________________________________
Parent (specify name): JOE--UNKNOWN _______________________________________________________
(e) Education (specify number of years of school or degrees completed at time of birth of adoptive child)
Parent (specify name): JANEY--HIGH SCHOOL _______________________________________________________
Parent (specify name): JOE--UNKNOWN _______________________________________________________
__________________________________________________________________________________________________________
Form 1C page 4
(f) General physical appearance at time of birth of adoptive child (height, weight, color of hair, eyes, skin)
BROWN HAIR AND EYES, WHITE FEMALE, 3 1/2 FEET TALL, 97 LBS
Parent (specify name): JANEY
Ht: 5'4" Wt: 140 LBS.
Hair color: BROWN Eye color: BROWN
Skin color: WHITE
Parent (specify name): JOE
Ht: 5'8" Wt: 150 LBS.
Hair color: BROWN Eye color: BROWN
Skin color: WHITE
(g) Annex Form 1D, which provides health and medical history at time of birth of adoptive child, including conditions or
diseases believed to be hereditary and any drugs or medication taken during pregnancy by child's mother.
(h) Any other information which may be a factor influencing the adoptive child's present or future wellbeing, including
talents, hobbies and special interests of parents: [attach separate sheet if necessary ]
JANE IS VERY VERBAL, BRIGHT AND LIKES TO DRAW. SHE'S VERY INDEPENDANT, PICKS HER OWN CLOTHES AND LIKES MUSIC
6. The manner in which the adoptive parent(s) obtained the adoptive child is as follows:
JANE IS THE BIRTH DAUGHTER OF JANEY DOE
7. The adoptive child has resided with the adoptive parent(s) from [indicate date ]: JANUARY 1, 1997 _____________________________________________________________________________________________________________________________________________________
8. Other persons living in the household are: [Specify names and dates of birth]: AMANDA DOE-DOB: 11-27-97, DAUGHTER OF JOHN, PETITIONING ADOPTIVE PARENT, AND JANEY,MOTHER OF ADOPTIVE CHILD. __________________________________________________________________________________________________________________________________
Form 1C page 5
9. The name by which the adoptive child is to be known is: JANE DOE
10. Upon information and belief, the adoptive child (has) (has not) been previously adopted.
11. The full name(s) and address(es) of any person(s) having lawful custody of the adoptive child, if known (is) (are)
JANEY DOE-MOTHER
1500 METROPOLITAN AVENUE, #10, BRONX, NY 10462
12. Upon information and belief, pursuant to Domestic Relations Law s 111,
(a) the consent of the birth or legal parent of the adoptive child (is attached hereto) (is not required because )
THE MOTHER, JANEY DOE, IS PART OF THIS PETITION.
(b) the consent of the other birth or legal parent of the adoptive child (is attached hereto) (is not required because
THE FATHER, JOE DOE, HAS HAD NO COMMUNICATION WITH THE CHILD SINCE HER BIRTH, HAS ABANDONED AND IN FACT REPUDIATED HIS RIGHTS AS FATHER BY THE ATTACHED AFFIDAVIT HE EXECUTED APRIL 22, 1996; HIS WHEREABOUTS ARE UNKNOWN TO DATE.
(c) the consent(s) of the abovenamed person(s) having lawful custody of the adoptive child (is attached hereto) (is not required because _______________________________________________________________________________________________;)
(d) the consent(s) of other person(s) [specify name(s) ]: (is attached hereto) (is not required because _____________________________________.)
13. (a) (The consent of the birth or legal parent [specify name ]: ______ was executed pursuant to section 115b(3) of the Domestic Relations Law on ______, 19___; the 45th day after execution of the consent is ______, 19___.)
Form 1C page 6
*(b) (The consent of the birth or legal parent [specify name ]: ______ was executed pursuant to Section 115b(3) of the Domestic Relations Law on ______, 19___; the 45th day after execution of the consent is ______, 19___.)
*(14. This court is not the court named in the consent(s) of the parent(s) of the adoptive child, attached hereto, as the court in which the adoption proceeding will be commenced, but more than 45 days have elapsed since the date of execution of said consent(s) and, on information and belief, no written notice of revocation has been received by that court.)
*(15. Upon information and belief, said minor child has a (general) (testamentary) guardian.) [state nature, date and place of appointment ]: ________________________________________________________________ ______________________________________________________________________________
16. To the best of the Petitioner(s)' information and belief, there are no persons other than those mentioned herein or in the verified schedule annexed hereto who are entitled, pursuant to Domestic Relation Law s 111(3) and 111a, to notice of this proceeding (except)
Name: JOE DOE Relationship: BIOLOGICAL FATHER
Last known address: SOMEWHERE IN FLORIDA
_______________________________________________
Name: ____________________ Relationship: ______
Last known address: ___________________________
_______________________________________________
Name: ____________________ Relationship: ______
Last known address: ___________________________
_______________________________________________
*17. The placement is subject to the provisions of Social Services Law section(s) (374a) (382) and the provisions of such section(s) have been complied with. The original approval signed by the Administrator of the Interstate Compact on the Placement of Children is attached hereto.
Form 1C page 7
18. (a) The adoptive parent(s) (has) (have) (no) knowledge that the child or an adoptive parent is the subject of an indicated report or is another person named in an indicated report of child abuse or maltreatment, as such terms are defined in section 412 of the Social Services Law, or has been the subject of or the respondent in a child protective proceeding which resulted in an order finding that the child is an abused or neglected child.
(b) The adoptive parent(s) (has) (have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except) NONE ______________________________________
19. There are no prior or pending proceedings affecting the custody or status of the adoptive child, including any proceedings dismissed or withdrawn, [FN*MV](except) [specify type of proceeding, court, disposition, if any, and date of disposition, if any ]: NONE ______________________________________________
20. The adoptive child (is) (is not) an Indian child within the meaning of the Indian Child Welfare Act of 1978 (25 U.S.C. ss 19011963).
21. [Insert any additional allegations.] NOT APPLICABLE
Form 1C page 8
WHEREFORE, the Petitioner(s) pray(s) for an order approving granting temporary guardianship of the child to Petitioner(s) and the adoption of the adoptive child [specify first name ]: JANE by the Petitioner(s) and directing that the adoptive child shall be treated in all respects as the child of the Petitioner(s) and directing that the name of the adoptive child be changed and that (s)he shall henceforth be known by the name of JANE DOE
together with such other and further relief as may be just and proper.
Dated: APRIL ____, 2004.
__________________________________________________ _________
Adoptive Parent: JOHN DOE signature
__________________________________________________ _________
Adoptive Parent: typed or printed name signature
_________
__________________________________________________ _________
Adoptive child, if over 18: typed or printed name signature
Form 1C page 9
VERIFICATION
STATE OF NEW YORK )
) ss.:
COUNTY OF NEW YORK
JOHN DOE being duly sworn, says that (he) (she) (they) (is) (are) the Petitioner(s) in the abovenamed proceeding and that the foregoing petition is true to (his) (her) (their) own knowledge, except as to matters where in stated to be alleged on information and belief and as to those matters (he) (she) (they) believe(s) it to be true.
__________________________________________________ _________
Adoptive Parent: JOHN DOE signature
__________________________________________________ _________
Adoptive Parent: typed or printed name signature
__________________________________________________ _________
Adoptive child, if over 18: typed or printed name signature
Sworn to before me this ___ day of APRIL, 1999.
__________________________________________
(Deputy) Clerk of the Court Notary Public
Resworn to before me this ______ day of ______, 19___.
____________________________________
Judge of the Surrogate's Court
__________________________________________________________