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D.R.L. §111(1) (a) Adoption Form 2-C (Consent of Child- Agency) 8/2002SURROGATE’S COURT OF THE STATE OF NEW YORKCOUNTY OF __________________________________In the Matter of Adoption of (Docket)(File) No.A Child Whose First Name Is CONSENT OF CHILD OVER 14___________________________________The undersigned adoptive child, who is years old, having been born on ,hereby consents to (his)(her) adoption by (and ), the petitioning adoptive parent(s) in the above-entitledproceeding.Dated:______________________________ Child ____________/______________________________ 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 numberSTATE 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 tome by satisfactory evidence as the person whose name is subscribed on this consent. (He)(She)acknowledged to me that (he)(she) executed this consent.________________________________Notary Public Form 2-C page 2STATE OF NEW YORK):ss.:COUNTY OF )On this day of , , before me personally came , proven to me by the oath ofan attorney admitted to practice in the State of New York to be the attorney admitted to practice in theState of New York to be the person described in and who executed the foregoing instrument and duly acknowledged that (he)(she) executed the same.__________________________________Judge of the Court

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