22 Petition (certification as a 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

New York Codes Rules Regulations (Last Updated: March 27,2024)

TITLE 22. Judiciary

Subtitle D. Forms

Chapter VII. Surrogate's Court Forms

Subchapter B. Adoption Forms of the Surrogate's Court

Adoption Forms

22 Petition (certification as a qualified adoptive parent) (private-placement)

D.R.L. §§ 115, 115-d

Form 22

(Certification

as Qualified

Adoptive Parent)

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

PETITION

by Adoptive Parent(s)

(Certification

as a Qualified

Adoptive Parent)

(Private-Placement)

________________

The Petitioner(s) respectfully allege(s) to this Court that:

[Delete inapplicable provisions]:

1. (His)(Her)(Their) name(s), residential address and telephone number are:

Petitioner (specify name):

2. (He)(She)(They) (is)(are) seeking certification by this court as (a) person(s) qualified to take custody of the adoptive child, [specify first name]:

, (prior to) (contemporaneous with) the filing of a private-placement adoption petition.

3. (He)(She)(They) (has)(have) (not) been the subject of a pending child protective investigation or of an indicated report, as such term is defined in section 412 of the Social Services Law, filed with the statewide register of child abuse and maltreatment pursuant to Title six of Article six of the Social Services Law.

4. A pre-placement investigation will be undertaken by a disinterested person, as such term is defined in section four of 115-d of the Domestic Relations Law and a written report of such investigation will be furnished directly to the court by such disinterested person.

5. The marital, family status and history of the Petitioner(s) (is) (are):

Petitioner (specify name):

6. The physical and mental health of the Petitioner(s) (is)(are):

Petitioner (specify name):

7. Attached hereto and made a part hereof is a statement of all property owned by and income of the Petitioner(s).

8 Petitioner(s) (has)(have)(not ever been) (a) respondent(s) in any proceeding in a court concerning alleged (abused) (neglected) (abandoned) children, (except as follows:)

Form 22 page 2

Petitioner (specify name):

(b) (Petitioner(s) (have) no prior criminal convictions or founded findings of child abuse or neglect (except as follows):

Petitioner (specify name):

Petitioner (specify name);

9. Petitioner(s) (has)(have)(not) made any prior application for certification as (a) qualified adoptive parent(s); if so, the disposition and disposition date of such application was as follows:

Petitioner (specify name):

Petitioner (specify name);

);

10. Petitioner(s) (do) (does) (not) intend to cause a pre-placement investigation to be undertaken (and request(s) this court to appoint a disinterested person to conduct such pre-placement investigation;)

WHEREFORE, Petitioner(s) pray(s) for an order (conditionally) certifying Petitioner(s) as (a) qualified adoptive parent(s).

Petitioner: typed or printed name/signature

Attorney if any: typed or printed name/signature

Attorney's Address and Telephone Number

Form 22 Page 3

VERIFICATION

STATE OF NEW YORK

)

ss.:

COUNTY OF

)

being duly sworn, says that (he)(she)(they) (is)(are) the Petitioner(s) in the above-named proceeding and that the foregoing petition is true to (his)(her)(their) own knowledge, except as to matters (he)(she)(they) believe(s) it to be true.

Adoptive Parent: typed or printed name/signature

Sworn to before me this

day of

, 19 .

(Deputy) Clerk of the Court Notary Public