New York Consolidated Laws Domestic Relations Law

Conditional Certification as Qualified Adoptive Parent

at

on

PRESENT:

The petition of verified the day of

, having been filed in this court on the day of , applying for certification as (a) qualified parent(s) of the adoptive child above-named; and

The petition and criminal history check indicating no prior criminal convictions as enumerated in Domestic Relations Law §115-d (3-a), pending child protective investigations, or founded findings of child abuse or neglect; and

A report having been filed herein by

, a disinterested person as defined in section 115-d of the Domestic Relations Law; and

This Court having determined, based upon the information submitted, that adoption of 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 the Court or required by any other statute or Court rule;

Form 25 page 2

Now, therefore, upon consideration of the report and all other relevant and material factors, it is hereby

ORDERED that

conditionally certified as (a) qualified adoptive parent(s) of the above-named adoptive child and may accept physical custody of such child for the purposes of adoption prior to or contemporaneous 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

Dated:

Check applicable box:

Order mailed on and to whom mailed ]:

Order received in court on and to whom given]: