Fill and Sign the Drl 111 111 a 112 115 Form 1 C Scpa17251

D.R.L.; §§111-a, 112(3), 112-bAdoption Form 1-BS.S.L. §§383-c, 384(Verified Schedule-Agency) 9/2008FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF In the Matter of the Adoption of(Docket) (File) No.A Child Whose First Name isVERIFIED SCHEDULE(Agency) TO THE COURT: 1. I , , am a duly constituted official of , the authorized agency whose principal office is at , and who G has custody of G is placingthe adoptive child named in the caption of this proceeding for adoption. 2. On information and belief, the full name, date and place of birth of the adoptive child are: [Attach certified copy of birth certificate] . 3a. On information and belief, the full name and last known address of the birth mother ofthe adoptive child are: 3b. On information and belief, the full name and last known address of the birth father ofthe adoptive child are: 4. This agency obtained custody of the adoptive child in the following manner: 5. [Applicable to Interstate Compact on Placement of Children cases]: The administrator ofthe Interstate Compact for the Placement of Children of the State of New York or his or her designee,has certified that such placement complied with the provisions of the compact. A true copy of thesigned document is attached and made a part of this schedule. 6. [Check applicable box(es)]: (a) The consent to this adoption by [specify]: ,birth mother of the adoptive child, Gis attached hereto Gis unnecessary for the following reasons[specify]: Form 1-B page 2 (b) The consent to this adoption by [specify]: ,birth father of the adoptive child, Gis attached hereto Gis unnecessary for the following reasons[specify]: 7. [Extra-judicial surrenders ONLY; delete applicable box; skip paragraph if inapplicable]: G [Applicable to child surrendered from foster care, pursuant to Soc. Serv. Law §383-c]: The birth parent(s) of the adoptive child Ghas/have G has/have not requested this agencyto return the adoptive child to the birth parent(s) within 45 days of the execution and delivery of aninstrument of surrender to an authorized agency, Gexcept [specify, if applicable]: G [Applicable to child surrendered who was NOT in foster care, pursuant to Soc. Serv. Law§384]: The birth parent(s) of the adoptive child Ghas/have G has/have not requested this agency toreturn the adoptive child to the birth parent(s) within 30 days of the execution and delivery of aninstrument of surrender to an authorized agency, Gexcept [specify, if applicable]: 8. Attached hereto and made a part hereof is a document setting forth all availableinformation comprising the adoptive child’s medical history. 9. [Applicable if there is a Post-adoption Contact Agreement; attach true copy]: G On [specify date]: , at the time of the approval of the surrenderof the child, the Family Court, [specify]: County, approved the attached Post-adoptionContact Agreement as being in the child’s best interests. The agreement was consented to in writing bythe following [specify]:Adoptive parent(s)[specify]:Birth parent(s) [specify]:Adoptive child’s law guardian [specify]:Sibling(s) or half-sibling(s) over the age of 14, if contact is with siblings or half-siblings [specify]:Date: Authorized AgencyBy Title___________________________________Signature of Attorney, if any___________________________________Attorney’s Name (Print or Type)______________________________________________________________________ Form 1-B page 3___________________________________Attorney’s Address and Telephone Number VERIFICATIONSTATE OF NEW YORK)ss.:COUNTY OF)being duly sworn,deposes and says: That (he) (she) is a duly constituted official of the above-named authorized agency, to wit, its; That (he) (she) has read the foregoing Schedule and knows the contents thereof; that the same is trueto (his) (her) own knowledge except as to matters therein stated to be alleged on information and belief and thatas to those matters (he) (she) believes it to be true. Agency OfficialSworn to before me this day of , . (Deputy) Clerk of the Court Notary Public