Fill and Sign the Drl 115 115 D Form 24 New York State Unified Court

D .R .L.§§ 115, 115-d Form 25 (Conditional C ertification as Q ualified A do ptive Parent) (8/2010) A t a term of the Fam ily C ourt of the State of N ew Y ork, held in and for the C ounty of , at ,N ew Y ork on P R E S E N T: H on. Judge ................................................... ......................... In the M atter of the A doption of A C hild W hose First N am e is (D ocket) (File) N o. O R D ER (C onditional C ertification as a Q ualified A doptive Parent) by A doptive Parent(s) ................................................... ........................... The petition of verified the day of , , having been filed in this court on the day of , , applying for certification as (a) qualified parent(s) of the ado ptive child above-nam ed; and The petition and crim inal history check indicating no prior crim inal convictions as enum erated in D om estic R elations Law §115-d (3-a), pending child protective investigations, or founded findings of child abuse or neglect; and A report having been filed herein by , a disinterested person as defined in section 115-d of the D om estic R elations Law ; and This C ourt having determ ined, based upon the inform ation subm itted, that adoption of the above-nam ed child by the Petitioner(s) is in the child’s best interests; and Pending com pletion of any further reports, investig ations or inquiries ordered by the C ourt or required by any other statute or C ourt rul e; Form 25 page 2 N ow , therefore, upon consideration of the report an d all other relevant and m aterial factors, it is hereby O R D ER ED that (is) (are) conditionally certified as (a) qualified adoptive p arent(s) of the above-nam ed adoptive child and m ay accept physical custody of such child for t he purposes of adoption prior to or contem poraneous w ith the filing of an adoption peti tion. N O TIC E: TH IS O R D ER O F C O N D ITIO N A L C ER TIFIC A TIO N IS V A LID U N TIL R EPLA C ED B Y A N O R D ER O F C ER TIFIC A TIO N O R B Y A N O R D E R D EN Y IN G CERTIFIC A TIO N , BU T IN N O EV EN T B EY O N D 180 D A Y S O F TH IS D A TE. [Applicable to Family Court Orders]: PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER 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. ENTER ____________________________________ (Judge of the Family Court.) (Surrogate) Dated: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________