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D.R.L. §114 Form 16-A(Application for Certified Copy of Adoption Order- After sealing of records) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF.................................................................... In the Matter of the Adoption of (Docket)(File) No. APPLICATION FOR CERTIFIED COPY OF ADOPTION ORDER (After sealing A Minor of the Age of years of records) ..................................................................... The undersigned applicant(s) respectfully show(s) that: 1. The applicants) (and) reside(s) at (and) (respectively) in the County of , State of 2. On or about the day of , , an order was made by the Honorable , a judge of the Court of County, State of New York, approving the adoption of the above- named child by , and thereafter the order was duly filed in the office of the Clerk of the Court of the County of , and sealed. 3. It is necessary for the applicant(s) to obtain a certified copy of the order approving the adoption because of the following facts and circumstances [Explain. Note: if the applicant is a Native-American individual 18 years of age or older who is seeking information and/or records regarding the birth parents’ tribal affiliation, so indicate]: . WHEREFORE, applicant(s) request(s) that the Court make an order directing the Clerk of the Court of the County of to prepare, certify Adoption Form 16-A page 2 and deliver to the applicant(s) a copy of the original order of adoption granted herein, and for such other and further relief as to the Court may be just and proper. Applicant Applicant________________________________ Print or type name(s) ________________________________ Signature of Attorney, if any________________________________ Attorney’s Name (Print or Type)________________________________________________________________ Attorney’s Address and Telephone Number VERIFICATION STATE OF NEW YORK ) )ss.: COUNTY OF ) , being duly sworn, say(s) that (he)(she)(they)(is)(are) the applicants) above named; that (he)(she)(they)(have)(has) read the foregoing application and the same is true to (his)(her)(their) knowledge except as to matters therein stated to be alleged on information and belief and as to those matters (he)(she)(they) believe(s) it to be true. Applicant Applicant Subscribed and sworn to before me this day of , . (Deputy) Clerk of the Court Notary Public