1-Ca Affidavit (change of circumstance since certification as qualified adoptive parent) (private-placement), Adoption Forms, Subchapter B. Adoption Forms of the Surrogate s Court, Chapter VII. Surrogate s Court Forms, Subtitle D. Forms, TITLE 22. Judiciary, New York Codes Rules Regulations

D.R.L. §§ 115, 115-d

Form 1-Ca

(Affidavit - Change of

Circumstance)

Private-Placement

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

(Change of

circumstance since

certification as qualified

adoptive parent)

(Private-Placement)

________________

STATE OF NEW YORK

)

:ss.:

COUNTY OF

)

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

1. Deponent(s) (was)(were) certified as (a) qualified adoptive parent(s) by order of the

Court, County of

, dated

, 19 ;

2. The following change(s) in circumstance relevant and material to such certification (has)(have) taken place since that date:

Date:

Petitioner

Print or type name

Signature of Attorney, if any

Attorney's Name (Print or Type)

______________

Attorney's Address and Telephone Number

Sworn to before me this

day of

, 19 .

______________