eLaws | eCases | State of New York |
 New York Codes Rules Regulations (Last Updated: March 27,2024)
 TITLE 22. Judiciary
 Subtitle D. Forms
 Chapter IV. Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7)
 Subchapter B. Adoption Forms of the Family Court
  Adoption Forms
  2-A Agreement of adoption and consent (agency)

  2-A Agreement of adoption and consent (agency)  

D.R.L. §§ 111 (1)(f), 112(2)(b),
 
Form 2-A
113
 
(Agreement of Adoption
 
and Consent—Agency)
 
8/2002
FAMILY 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 AND
 
CONSENT (Agency)
________________
The undersigned 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) (parents) 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
Form 2-A Page 2
The undersigned authorized agency hereby consents to the adoption of the above-named adoptive child by the petitioning adoptive parent(s).
Name of Authorized Agency:
 
______________
 
By: ______________
Title
STATE OF NEW YORK
 
)
 
 
ss:
 
COUNTY OF
 
 
)
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 and consent.
Notary Public
STATE OF NEW YORK
 
)
 
 
ss:
 
COUNTY OF
 
 
)
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 and consent.
Notary Public
Form 2-A Page 3
STATE OF NEW YORK
 
)
 
 
ss:
 
COUNTY OF
 
 
)
On this
 
day of
 
, , before me personally came
 
, to me known and who by me being duly sworn did depose and say: That he/she resides at
County of
 
State of
 
: that he/she is [specify position]: of [specify authorized agency]:
(an authorized agency), the corporation described in and which executed the foregoing instrument, that he/she knows the seal of said corporation; that such seal affixed to said instrument is such corporate seal; that it was affixed to said instrument by order of the Board of
 
of such corporation in writing, and that he/she signed his/her name thereto.
Notary Public
State of New York
 
)
 
 
ss.:
 
County of
 
 
)
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 who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same.
Judge of the Court