Fill and Sign the Form 23 Download Fillable PDF Affidavit and Report

D.R.L §§ 115, 115-d. Form 23(Certificationas QualifiedAdoptive Parent)9/99SURROGATE’S COURT OF THE STATE OF NEW YORKCOUNTY OF In the Matter of the Adoption ofA Child Whose First Name Is(Docket)(File) No.AFFIDAVIT andREPORT (DisinterestedPerson-CertificationbyProceeding)Adoptive Parent(Private-Placement) State of New York):ss..County of) being duly sworn deposes and says that:1. (He)(She) is a disinterested person as such person is defined in section 115-d of theDomestic Relations Law in that:and has no interest in the out come of the application of the part(y)(ies) herein for certification asqualified adoptive apparent(s);2. The following fee(s) (have been) (will be) paid to deponent for services rendered inconnection with the pre-placement investigation performed in connection with this certificationproceeding: ;3. The following is deponent's report of (his)(her) investigation into the truth and accuracyof the allegations set forth in the petition of , as qualifiedadoptive parents in the proceeding for certification and (deponent's investigation of the various factorsrelevant to the suitability of the petitioners as qualified adoptive parents: Form 23 page 2(a) Date, place and duration of personal interview and visit at petitioners home:(b) Report:(c) other facts relating to familial, social, religious, emotional and financial circumstances of petitioners relevant to certification as a qualified adoptive parent(s).Dated:___________________________________ Affiant (Disinterested Person)___________________________________Print or type nameSworn to before methis dayof , . Notary Public