Fill and Sign the New York Consolidated Laws Domestic Relations Law Dom Form

D.R.L.§§ 115, 115-d Form 25 (Conditional Certification as Qualified Adoptive Parent)(8/2010)At a term of the Family Court of theState of New York, held in and for the County of ,at ,New YorkonP R E S E N T:Hon. Judge............................................................................In the Matter of the Adoption ofA Child Whose First Name is(Docket) (File) No.ORDER(Conditional Certificationas a Qualified Adoptive Parent)byAdoptive Parent(s)..............................................................................The petition of verified the day of , , having been filed in this court on the day of , , applying forcertification as (a) qualified parent(s) of the adoptive child above-named; andThe petition and criminal history check indicating no prior criminal convictions asenumerated in Domestic Relations Law §115-d (3-a), pending child protective investigations,or founded findings of child abuse or neglect; andA report having been filed herein by , a disinterestedperson as defined in section 115-d of the Domestic Relations Law; and This Court having determined, based upon the information submitted, that adoptionof the above-named child by the Petitioner(s) is in the child’s best interests; and Pending completion of any further reports, investigations or inquiries ordered by theCourt or required by any other statute or Court rule; Form 25 page 2Now, therefore, upon consideration of the report and all other relevant and materialfactors, it is herebyORDERED that (is) (are)conditionally certified as (a) qualified adoptive parent(s) of the above-named adoptive childand may accept physical custody of such child for the purposes of adoption prior to orcontemporaneous with the filing of an adoption petition.NOTICE:THIS ORDER OF CONDITIONAL CERTIFICATION IS VALID UNTIL REPLACED BY AN ORDER OF CERTIFICATION OR BY AN ORDER DENYING CERTIFICATION, BUT IN NO EVENT BEYOND 180 DAYS OF THIS DATE.[Applicable to Family Court Orders]: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 FROM 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: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________