Fill and Sign the L 115 115 D Form

D.R.L§§ 115, 115-dFrom 24 (Certification as Qualified Adoptive Parent) (8/2010) At a term of the Family Court of the State of New York, held in and for the County of , at New Yorkon , . PRESENT: Hon. Judge In the Matter of the Adoption of (Docket)(File) No. A Child Whose First Name is ORDER (Certification as a Qualified Adoptive by Parent) Adoptive Parent NOTICE: THIS ORDER IS VALID ONLY UNTIL The petition of , verified the day of , , and filed in this court on the day of , , applying for certification as (a) qualified parent(s) of the above-named adoptive child and a report having been filed herein by , a disinterested person as defined in section 115-d of the Domestic Relations Law, AND a criminal history check having been performed and such check having revealed no criminal convictions enumerated in section 115-d(3-a) of the Domestic Relations Law (except [specify; delete if inapplicable]: AND this Court having determined that the best interests of the above-named adoptive child [check applicable box]: G will G will not be promoted by the adoption by the Petitioner(s), Now therefore upon consideration of the report and all other relevant and material factors, it is hereby G ORDERED that are certified as (a) qualified adoptive Form 24 page 2 parent(s) of the above-named adoptive child and may accept physical custody of a child for the purposes of adoption prior to or contemporaneous with the filing of an adoption petition. OR G ORDERED that the application by for certification as (a) qualified adoptive parent(s) is hereby denied for the following reasons: .) 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 FORM 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: Q Order mailed on specify date(s) and to whom mailed]: Q Order received in court on [specify date(s) and to whom given]: