Fill and Sign the Adoptive Parent Form

D.R.L. §§ 115, 115-dForm 22 (Certification As Qualified Adoptive Parent) 9/99 ................................................................. 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): 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): Petitioner (specify name): 6. The physical and mental health of the Petitioner(s) (is)(are): Petitioner (specify name): 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). Form 22 page 21 Fingerprint cards must be provided to the Court so that a criminal history report can be obtained from the N.Y.S. Division of Criminal Justice Services pursuant to Domestic Relations Law Section 115-d(3-a). 2 Applicable only if petition seeks conditional certification pursuant to D.R.L. Section 115-d(6). 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): Petitioner (specify name): Petitioner (specify name): (b) (Petitioner(s) (have) no prior criminal convictions or founded findings of child abuse or neglect (except as follows):1 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)2 certifying Petitioner(s) as (a) qualified adoptive parent(s). ______________________________________/______________________________ Petitioner: typed or printed name / signature ______________________________________/_______________________________ Petitioner: typed or printed name / signature _______________________________/___________________________ Attorney: typed or printed name/ signature ______________________________________________________________________ Form 22 page 3 Attorney’s Address and Telephone Number Form 22 Page 4 VERIFICATIONSTATE 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 on information and belief and as to those matters (he)(she)(they) believe(s) to be true. ______________________________________/________________________________ Petitioner: typed or printed name/ signature _______________________________________/_______________________________ Petitioner: typed or printed name/ signature Sworn to before me this day of , . ___________________________ (Deputy) Clerk of the Court Notary Public