Fill and Sign the Drl111 A1 112 Form 1 a Adoption Petition Agency

D.R.L. §§ 111(3), 111-a(6),115(9).Adoption Form 4 (Notice of Proposed Adoption)10/2004FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF _________________________________In the Matter of the Adoption of G Docket G File No.A Child whose First Name is NOTICE OF PROPOSED ADOPTION _________________________________To:PLEASE TAKE NOTICE that a petition requesting an order approving and allowingthe adoption of an adoptive child whose first name is [specify]: , who isalleged to be your [specify relationship]: , and whose full name anddate and place of birth is set forth in a Schedule annexed to the petition for adoption herein,together with an agreement to adopt and consents to the adoption pursuant to the DomesticRelations Law, has been filed with the [specify]: Court of the State of NewYork, County. A hearing on the petition will be held at the Court, located at[specify address]:on [specify date]: , at [specify time]: o'clock in the G morning G afternoon ofthat day, at which time and place all persons having any interest therein will be heard.[Check box if applicable pursuant to Domestic Relations Law §111-a(6)]: Q PLEASE TAKE FURTHER NOTICE that your failure to appear may constitute adenial of your interest in the child, which may result, without further notice to you, in theadoption or other disposition of the custody of the child. Signature of Petitioner’s Attorney __________________________ Attorney’s Name (print or type) ___________________________ ___________________________ Attorney’s Address and Telephone Number