Fill and Sign the Dom 112 B the New York State Senate Form

D.R.L. §§111, 112(b), 113, 114 Adoption Form 13-B(Order of Adoption- Private-Placement) 8/2010 At a term of the Family Court of the State of New York, held in and for the County of , at New Yorkon , . PRESENT: Hon. Judge____________________________________ In the Matter of the Adoption of QD ocket QFile N o. A Child Whose First Name Is ORDER OF ADOPTION (Private-Placement) ____________________________________ The Petition of (and), verified the day of , , having been duly presented to this Court, together with an agreement on the part of the petitioning adoptive parent(s) to adopt and treat as Qhis Qher Qtheir own lawful child the adoptive child, whose first name is [specify]: and whose birth day is [specify]: , and who was born at [specify]: , as set forth in the petition for adoption herein, and the petition having a document attached thereto and made a part thereof setting forth all available information comprising the adoptive child's medical history; together with the affidavit(s) of [specify]: and the consent(s) of [specify]: ; [Check applicable box(es)]: AND, although Qhis Qher Qtheir consent(s) Qis/are Q is/are not required, the Court having given notice of the proposed adoption to [specify]: AND the aforesaid petitioning adoptive parents and the adoptive child and all other persons whose consents are required having personally appeared before this Court for examination, except [specify]: ; AND an investigation having been ordered and made and the written report of such investigation having been filed with the Court, as required by the Domestic Relations Law; [Check box(es) if applicable]: Q AND the Court having Q shortened Q dispensed with the three-month waiting period between its receiving the petition to adopt and this order of adoption, pursuant to section 116 of the Domestic Relations Law, because [specify Form 13-B Page 2 reason(s)]: ; AND the adoptive child having resided with the petitioning adoptive parent(s) since (and the judge having dispensed with the three-month period of residency with the adoptive parent(s), pursuant to section 112 and 116 of the Domestic Relations Law because ; [Check box(es) if applicable]: Q AND the court having inquired of the statewide central register of child abuse and maltreatment and having been informed that the Q child Q adoptive parent(s) Q is/are Q is/are not a subject of, or another person named in, an indicated report filed with the register as such terms are defined in section 412 of the Social Services Law, Q AND there being available to this Court findings of a court inquiry made within the preceding twelve months, of the statewide central register of child abuse and maltreatmentthat the Q child Q adoptive parent(s) Q is/are Q is/are not a subject of, or another person named in, an indicated report filed with such register as such terms are defined in section 412 of the Social Services Law, and the Court having given due consideration to any information contained therein; AND this Court being satisfied that the best interests of the adoptive child will be promoted by the adoption and that there is no reasonable objection to the proposed change of the name of the adoptive child; [Required in cases involving Native-American children; check if applicable ]: “ And the following having been duly notified [check applicable box(es)]: “ parent/custodian “ tribe/nation “ United States Secretary of the Interior; And the tribe/nation having: “ appeared “ not appeared; NOW , on motion of [specify]: , Attorney for the petitioners herein, and upon all the papers and proceedings herein, it is ORDERED that the petition of (and )for the adoption of a person born on , , at , is allowed and approved; and it is further ORDERED that the adoptive child shall henceforth be regarded and treated in all respects as the lawful child of the adoptive parent(s); and it is further ORDERED that the name of the adoptive child is changed to [specify]: and that the adoptive child shall hereafter be known by that name; and it is further Form 13-B Page 3 [Check box if applicable]: Q ORDERED that the Clerk prepare, certify and deliver a copy of this order to [specify]: ; and it is further ORDERED that the child's medical history; heritage of the parents, which shall include nationality, ethnic background and race; education, which shall be the number of years of school completed by the parents at the time of the birth of the adoptive child; general physical appearance of the parents at the time of the birth of the adoptive child, including height, weight, color of hair, eyes, skin; occupation of the parents at the time of birth of the adoptive child; health and medical history of the parents at the time of birth of the adoptive child, including all available information setting forth conditions or diseases believed to be hereditary, any drugs or medication taken during pregnancy by the mother; and other information which may be a factor influencing the child's present or future well-being; and talents, hobbies and special interests of the parents as contained in the petition, shall be furnished to the adoptive parents; and it is [Check box if applicable]: G ORDERED that, if required by a governmental agency, including but not limited to, the United States Social Security Administration, the United States Passport Office and the New York State Department of Motor Vehicles, in connection with an application submitted by or on behalf of the adoptive child, the adoptive parent(s)’ attorney [specify]: is authorized to deliver a certified copy of this Order of Adoption to such agency directly or to the adoptive parent, as he or she deems appropriate; and it is further ORDERED that this order, together with all other papers pertaining to the adoption, shall be filed and kept as provided in the Domestic Relations Law and shall not be subject to access or inspections except as provided in this Order or such Law. ENTER: ______________________________ 9 Judge of the Family Court 9 Surrogate Dated: , . [Applicable to orders of the Family Court]: PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM AN ORDER OF THE FAMILY COURT MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. C heck ap p licab le b o x: 9 O rd er m ailed o n [sp ecify d ate(s) and to w ho m m aile d ]:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 9 O rd er received in co urt o n [sp ecify d ate(s) and to w ho m given]:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _