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D.R.L.§§ 111, 111-a, 112, 115 Form 1-CS.C.P.A. § 1725(1) (Petition-Private -Placement) 9/2008FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF........................................................In the Matter of Adoption of(Docket)(File) No.A Child Whose First Name Is PETITION FORADOPTION(Private-Placement).......................................................... The Petitioner(s) respectfully allege(s) to this Court that :[Delete inapplicable provisions.]: 1. 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]:c. is (unmarried) (married to [specify name]: and living together (married to [specify name]: and living separateand apart pursuant to a decree or judgment of separation or pursuant to a separation agreementsubscribed by the parties thereto and acknowledged or proved in the form required to entitle adeed to be recorded); (married to [specify name]: and living separate andapart for at least three years prior tocommencement of the proceeding);d. is of the following religious faith, if any:e. is engaged in the following occupation [specify]: and earns $ (of which $ is support and maintenance to be received from the Commissioner of SocialServices on behalf of the adoptive child). 2. Petitioning adoptive parent [specify name]: a. resides at [specify address, including county]: Form 1-C page 2b. is of full age, having been born on [specify date of birth]:c. is (unmarried) (married to [specify name]: and living together (married to [specify name]: and living separateand apart pursuant to a decree or judgment of separation or pursuant to a separation agreementsubscribed by the parties thereto and acknowledged or proved in the form required to entitle adeed to be recorded); (married to [specify name]: and living separate and apart for atleast 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 receivedfrom 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[attach certified copy of birth certificate] 4. Upon information and belief, the religious faith of the adoptive child, if any, is . 5. The following is information, as nearly as can be ascertained, concerning the birth orlegal parents of the adoptive child:(a) Full name and last known address Parent (specify full name and address, if known): Parent (specify full name and address, if known):(b) Age and date of birth Parent (specify name): Parent (specify name):(c) Heritage (specify nationality, ethnic background, race)Parent (specify name):Parent (specify name): Form 1-C page 3(d)Religious faith, if anyParent (specify name):Parent (specify name): (e)Education (specify number of years of school or degrees completed at timeof birth of adoptive child)Parent (specify name):___________________________________Parent (specify name):___________________________________(f)General physical appearance at time of birth of adoptive child (height,weight, color of hair, eyes, skin) Parent (specify name): Ht:_________ Wt:____________ Hair Color: ___________ Eye Color: _______ Skin Color: __________Parent (specify name): Ht:_________ Wt: ___________ Hair Color: __________ Eye Color:__________ Skin Color: __________ (g) Annex Form 1-D which provides health and medical history at time of birth ofadoptive child, including conditions or diseases believed to be hereditary and any drugs ormedication taken during pregnancy by child's mother.(h) Any other information which may be a factor influencing the adoptive child'spresent or future well-being, including talents, hobbies and special interests of parents: [attach separate sheet if necessary] 6. The manner in which the adoptive parent(s) obtained the adoptive child is as follows: 7. The adoptive child resided with the adoptive parent(s) from [indicate date]: . 8. Other persons living in the household are: [Specify names and dates of birth]: . 9.The name by which the adoptive child is to be known is: . 10. Upon information and belief, the adoptive child (has) (has not) been previouslyadopted. 11. The full name(s) and address(es) of any person(s) having lawful custody of theadoptive child, if known (is)(are) Form 1-C page 4 12.On information and belief, pursuant to Domestic Relations Law §111, (a) the consent of the birth or legal parent of the adoptive child “is attached hereto “is notrequired because (b) the consent of the birth or legal parent of the adoptive child “is attached hereto “is notrequired because (c) the consent(s) of the above-named person(s) having lawful custody of the adoptive childchild “is attached hereto “is not required because (d) The consent(s) of other person(s)[specify name(s)]: child “is attached hereto “is not required because 13(a)(The consent of the birth or legal parent [specify name]: was executedpursuant to section 115-b(3) of the Domestic Relations Law on______________, _____; the 45th day after execution of the consent is _______________,_____. (b) (The consent of the birth or legal parent [specify name]: wasexecuted pursuant to Section 115-b(3) of the Domestic Relations Law on _______________, _____; the 45th day after execution of the consent is ______________,______.) [DELETE IF INAPPLICABLE]: 14. This court is not the court named in the consent(s) of theparent(s) of the adoptive child, attached hereto, as the court in which the adoption proceeding willbe 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.) [DELETE IF INAPPLICABLE]: 15. On information and belief, the 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 thanthose mentioned herein or in the verified scheduled annexed hereto who are entitled, pursuant toDomestic Relation Law §111(3) and 111-a, to notice of this proceeding (except) Name: Relationship: Last known address: . Name Relationship: Last known address: . Form 1-C page 5 Name Relationship: Last known address: . 17. The child “ is “is not under the jurisdiction of the Family Court. If so, this petition “ has “ has not been filed in the Court that exercised jurisdiction over the most recentpermanency or other proceeding involving this child. [If it has not been so filed, petitioner mustfile affirmation, Adoption Form 1-E]. 18. Attached hereto and made a part hereof is Form 1-D setting forth all available informationcomprising the adoptive child's medical history. [DELETE IF INAPPLICABLE]: 19. The placement is subject to the provisions of SocialServices Law section(s) “374-a “ 382 and the provisions of such section(s) have been compliedwith. The original approval signed by the Administrator of the Interstate Compact on thePlacement of Children is attached hereto. 20. (a) The adoptive parent(s) “ has/have “ has/have no knowledge that the child or anadoptive parent is the subject of an indicated report or is another person named in an indicatedreport of child abuse or maltreatment, as such terms are defined in section 412 of the SocialServices Law, or has been the subject of or the respondent in a child protective proceeding whichresulted in an order finding that the child is an abused or neglected child.(b) The adoptive parent(s) “ has/have “ has/have no knowledge of any criminal recordconcerning themselves or any other adult over the age of 18 residing in the household (except) . 21. There are no prior or pending proceedings affecting the custody or status of the adoptivechild, including any proceedings dismissed or withdrawn, (except) [specify type of proceeding,court, disposition, if any, and date of disposition, if any]: 22. The subject child “ is “ is not a Native-American child, who is subject to the Indian ChildWelfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicablebox(es)]:“ parent/custodian [specify name and give notification date]:“ tribe/nation [specify name and give notification date]:“ United States Secretary of the Interior [give notification date]: 23.[Insert any additional allegations.] . Form 1-C page 6 WHEREFORE, the Petitioner(s) request(s) an order approving granting temporaryguardianship of the child to Petitioner(s) and the adoption of the adoptive child [specify firstname]: by the Petitioner(s) and directing that the adoptivechild shall be treated in all respects as the child of the Petitioner(s) and directing that the name ofthe adoptive child be changed and that (s)he shall henceforth be known by the name of [specify]: together with such other and further relief as may be just and proper.Dated: , .______________________________________/_______________________________Adoptive Parent: typed or printed name/ signature______________________________________/________________________________Adoptive Parent: typed or printed name / signature_________________________________________________/_____________________Adoptive child if over 18: typed or printed name / signature*_______________________________________/_______________________________Attorney , if any: typed or printed name/ signature______________________________________________________________________Attorney’s Address and Telephone Number* Note: Consent of a child over 14 must be attached. Form 1-C page 7 VERIFICATIONSTATE OF NEW YORK):ss.:COUNTY OF)being duly sworn, says that (he)(she) (they)(is)(are) the Petitioner(s) in the above-namedproceeding and that the foregoing petition is true to (his)(her)(their) own knowledge, except as tomatters 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: typed or printed name/ signature______________________________________/_____________________________Adoptive Parent: typed or printed name/ signature________________________________________________/_____________________Adoptive child if over 18: typed or printed name/ signatureSworn to before me this day of , .__________________________(Deputy)Clerk of the Court Notary PublicResworn to before me this day of , ._______________________________Judge of the Court

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