Fill and Sign the 115 115 D9 Form

D.R.L. §§ 115, 115-d(9)Form 26 (Certification Petition for Extension of Expired Certification - Private Placement) 9/99 .................................................................In the Matter of the Adoption ofA Child whose First Name is (Docket)(File) No. PETITION by Adoptive Parent(s) FOR EXTENSION OF EXPIRED CERTIFICATION (Private Placement) ................................................................... The Petitioner(s) respectfully allege(s) to this Court that: 1. (He)(She)(They) filed a petition to adopt the above-described child in this Court on , . 2. Petitioner(s) (was)(were) certified as a qualified adoptive parent(s), by order of the Court, County of , dated , , which order expired on , , within one year prior to the filing of the adoption petition. 3. The following change(s) in circumstances relevant and material to such certification (has)(have) taken place since issuance and expiration of the last certification: 4. Submitted herewith is written verification of any such change in circumstances or lack thereof by , a disinterested person as defined in section 115-d(4) of the Domestic Relations Law. WHEREFORE, Petitioner(s) (prays) (prays) for an order extending the termination date of the earlier certification until eighteen months from the date of filing of the adoption petition, that is, ______________________________________/______________________________ Adoptive Parent: typed or printed name/ signature ________________________________________________/_____________________ Adoptive Parents: typed or printed name/ signature _______________________________________/______________________________ Attorney: typed or printed name/ signatur e ___________________________________________________________ Attorney’s Address and Telephone Number Form 26 page 2 VERIFICATION STATE OF NEW YORK ) ss: COUNTY ) 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 therein stated to be alleged oninformation 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 Sworn to before me this day of , . _______________________________ (Deputy)Clerk of the Court Notary Public Resworn to before me this day of , . ________________________________ Judge of the Court