Fill and Sign the Drl115 115 D Form 22 Certification as Qualified

D.R.L. §§ 115, 115-dForm 22 (Certification As Qualified Adoptive Parent) 9/99.................................................................In the Matter of the Adoption of (Docket)(File) No.A Child whose First Name is PETITIONby Adoptive Parent(s) (Certification as a Qualified Adoptive Parent) (Private-Placement).................................................................The Petitioner(s) respectfully allege(s) to this Court that: [Delete inapplicable provisions]:1. (His)(Her)(Their) name(s), residential address and telephone number are:Petitioner (specify name):Petitioner (specify name):2. (He)(She)(They) (is)(are) seeking certification by this court as (a) person(s) qualified to takecustody of the adoptive child [specify first name]: , (prior to)(contemporaneous with) the filing of a private-placement adoption petition.3. (He)(She)(They) (has) (have) (not) been the subject of a pending child protectiveinvestigation or of an indicated report, as such term is defined in section 412 of the Social ServicesLaw, filed with the statewide register of child abuse and maltreatment pursuant to Title six of Articlesix of the Social Services Law.4. A pre-placement investigation will be undertaken by a disinterested person, as such term isdefined in section four of 115-d of the Domestic Relations Law, and a written report of suchinvestigation will be furnished directly to the court by such disinterested person.5. The marital, family status and history of the Petitioner(s) (is) (are): Petitioner (specify name):Petitioner (specify name):6. The physical and mental health of the Petitioner(s) (is)(are): Petitioner (specify name):Petitioner (specify name):7. Attached hereto and made a part hereof is a statement of all property owned by and incomeof the Petitioner(s).8. Petitioner(s) (has) (have)(not ever been) (a) respondent(s) in any proceeding in a courtconcerning alleged (abused) (neglected) (abandoned) children, (except as follows): Form 22 page 21Fingerprint cards must be provided to the Court so that a criminal history report can be obtained from theN.Y.S. Division of Criminal Justice Services pursuant to Domestic Relations Law Section 115-d(3-a).2Applicable only if petition seeks conditional certification pursuant to D.R.L. Section 115-d(6).Petitioner (specify name):Petitioner (specify name):(b) (Petitioner(s) (have) no prior criminal convictions or founded findings of child abuse orneglect (except as follows):1Petitioner (specify name):Petitioner (specify name):9. Petitioner(s) (has)(have) (not) made any prior application for certification as (a) qualifiedadoptive parent(s); if so, the disposition and disposition date of such application was as follows:Petitioner (specify name):Petitioner (specify name): );10. Petitioner(s) (do)(does) (not) intend to cause a pre-placement investigation to beundertaken (and request(s) this court to appoint a disinterested person to conduct such pre-placementinvestigation;)WHEREFORE, Petitioner (s) pray(s) for an order (conditionally)2 certifying Petitioner(s) as (a)qualified adoptive parent(s).______________________________________/______________________________Petitioner: typed or printed name / signature______________________________________/_______________________________Petitioner: typed or printed name / signature_______________________________/___________________________Attorney: typed or printed name/ signature______________________________________________________________________Attorney’s Address and Telephone Number Form 22 Page 3VERIFICATIONSTATE OF NEW YORK)ss:COUNTY)being duly sworn, says that (he)(she)(they) (is)(are) the Petitioner(s) in the above-named proceedingand that the foregoing petition is true to (his)(her)(their) own knowledge, except as to matters thereinstated to be on information and belief and as to those matters (he)(she)(they) believe(s) to be true.______________________________________/________________________________Petitioner: typed or printed name/ signature_______________________________________/_______________________________Petitioner: typed or printed name/ signature Sworn to before me this day of , .___________________________(Deputy) Clerk of the Court Notary Public