Fill and Sign the Affidavit and Report Disinterested Person Extension of Form

D.R.L. §§ 115, 115-d (9)Form 26-a(Certification as Qualified Adoptive Parent)9/99SURROGATE’S COURT OF THE STATE OF NEW YORKCOUNTY OF In the Matter of the Adoption of(Docket) (File) No.A Child Whose First Name isAFFIDAVIT and REPORT(Disinterested Person-Extension of Expired byCertification)Adoptive Parent(s) [Name] , being duly sworn, deposes andsays that:1. I am a disinterested person as defined in section 115-d (4) of the Domestic Relations Lawin that (he) (she) has no interest in the outcome of the application of the part (y) (ies) herein forcertification as (a) qualified adoptive parent (s).2. The following fee (s) (have been) (will be) paid to deponent for services rendered inconnection with the application for extension of certification:3. I have read the affidavit and report prepared by and submitted in support of the petition for certification as (a) qualified adoptive parent (s) submittedby petitioner (s) on , . On information and belief, an order grantingcertification as a qualified adoptive parent (s) was made by the Court, County, on , , and expired on , . 4. The following Change (s) in circumstances relevant and material to the extension of suchcertification (has) (have) taken place since the issuance and expiration of the last certification:5. The source of my knowledge concerning the circumstances of the petitioner’s (s’) familyand household is: [include date, place and duration of personal interview and visit at petitioner’s (s’)home.] Form 26-a page 2Dated: ___________________________________ Affiant (Disinterested Person)___________________________________Print or type nameSworn to before me this day of , . Notary Public