Fill and Sign the Matrimonial Court Report Unified Court System Form

D.R.L.§ 111(1)(f), 112(2)(b)113 Form 2-A (Agreement of Adoption an d C on se nt -- Agen cy) 8/2002 SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF _________________________________ In the Matter of the Adoption of (Docket)(File) No. A Ch ild Whos e Fi rst Nam e Is AGREEMENT OF ADOPTION AND CO NS EN T ( Agen cy) __________________________________ The undersigned petitioning adoptive parent(s) hereby agree(s) to adopt the above-named adoptive child and to treat said child in all respects as (his) (her) (their) own lawful child and to extend and assure to said child all the rights, benefits and privileges incident to such relationship, and to incur and fulfill all the responsibilities of (a parent) (parents) with respect to said child. Dated: ______________________________________/______________________________ Adoptive Parent: typed or printed name/ signature ______________________________________/_______________________________ Adoptive Parent: typed or printed name / signature _______________________________________________/_______________________ Adoptive child if over 14: typed or printed name/ signature ______________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney’s Address and Telephone number Form 2-A Page 2 The undersigned authorized agency hereby consents to the adoption of the above-named adoptive child by the petitioning adoptive parent(s). Na me of Au th or iz ed Agen cy: ___________________________ By: ______________________________________________________ Title STATE OF NEW YORK ) ss: COUNTY ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement and consent. ___________________________Notary Public STATE OF NEW YORK )ss: COUNTY ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement and consent. ___________________________Notary Public Form 2-A Page 3 STATE OF NEW YORK ) ss: COUNTY ) On this day of , , before me personally came , to me kn ow n a nd wh o b y me be in g d ul y sw or n d id de po se an d s ay: That he/she resides at County of State of : that he/she is [specify position]: of [specify authorized agency]: (an authorized agency), the corporation described in and which executed the foregoing instrument, that he/she knows the seal of said corporation; that such seal affixed to said instrument is such corporate seal; that it was affixed to said instrument by order of the Board of of such corporation in writing, and that he/she signed his/her name thereto. ____________________________ Notary Public State of New York ) ss.: County of ) On this day of , , , proven to me by the oath of , an attorney admitted to practice in the State of New York, to be the person who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same. ________________________________Judge of the Court