New York State Adoption Form DRL-111

ORDER OF ADOPTION (PRIVATE-PLACEMENT)

PRESENT:

Hon.

Judge

ORDER OF
ADOPTION
(Private-Placement)

The Petition of

), verified the day of , (and

, having been duly presented to this Court, together with an agreement on the part of the petitioning adoptive

parent(s) to adopt and treat as his her their own lawful child the adoptive child, whose first

name is :

, and who was born at and whose birth day is :

as set forth in the petition for adoption herein, and the petition having a document attached

thereto and made a part thereof setting forth all available information comprising the adoptive

child's medical history; together with the affidavit(s) of :

and the consent(s) of ;

[Check applicable box(es)]: AND, although his her their consent(s) is/are

is/are not required, the Court having given notice of the proposed adoption to :

AND the aforesaid petitioning adoptive parents and the adoptive child and all

other persons whose consents are required having personally appeared before this Court for

examination, except ;

AND an investigation having been ordered and made and the written report of

such investigation having been filed with the Court, as required by the Domestic Relations Law;

[Check box(es) if applicable]: AND the Court having shortened

dispensed with the three-month waiting period between its receiving the petition to adopt and

this order of adoption, pursuant to section 116 of the Domestic Relations Law, because

reason(s)]:

;

AND the adoptive child having resided with the petitioning adoptive parent(s)

since (and the judge

having dispensed with the three-month period of residency with the adoptive parent(s), pursuant

to section 112 and 116 of the Domestic Relations Law because

[Check box(es) if applicable]: AND the court having inquired of the statewide

central register of child abuse and maltreatment and having been informed that the child adoptive parent(s) is/are is/are not a subject of, or another person named in, an

indicated report filed with the register as such terms are defined in section 412 of the Social

Services Law,

AND there being available to this Court findings of a court inquiry made within

the preceding twelve months, of the statewide central register of child abuse and maltreatment

that the child adoptive parent(s) is/are is/are not a subject of, or another person

named in, an indicated report filed with such register as such terms are defined in section 412 of

the Social Services Law, and the Court having given due consideration to any information

contained therein;

AND this Court being satisfied that the best interests of the adoptive child will be

promoted by the adoption and that there is no reasonable objection to the proposed change of the

name of the adoptive child;

[Required in cases involving Native-American children; check if applicable ]:

And the following having been duly notified [check applicable box(es)]:

parent/custodian

tribe/nation United States Secretary of the Interior;

And the tribe/nation having: appeared not appeared;

NOW, on motion of :

Attorney for the petitioners herein, and upon all the papers and proceedings herein, it is

ORDERED that the petition of (and

)for the adoption of

a person born on at

, is allowed and approved; and it is further

ORDERED that the adoptive child shall henceforth be regarded and treated in all

respects as the lawful child of the adoptive parent(s); and it is further

ORDERED that the name of the adoptive child is changed to :

and that the adoptive child shall hereafter be known by that name; and it is further

[Check box if applicable]: ORDERED that the Clerk prepare, certify and

deliver a copy of this order to ; and it is further

ORDERED that the child's medical history; heritage of the parents, which shall include

nationality, ethnic background and race; education, which shall be the number of years of school

completed by the parents at the time of the birth of the adoptive child; general physical

appearance of the parents at the time of the birth of the adoptive child, including height, weight,

color of hair, eyes, skin; occupation of the parents at the time of birth of the adoptive child;

health and medical history of the parents at the time of birth of the adoptive child, including all

available information setting forth conditions or diseases believed to be hereditary, any drugs or

medication taken during pregnancy by the mother; and other information which may be a factor

influencing the child's present or future well-being; and talents, hobbies and special interests of

the parents as contained in the petition, shall be furnished to the adoptive parents; and it is

[Check box if applicable]: ORDERED that, if required by a governmental agency,

including but not limited to, the United States Social Security Administration, the United States

Passport Office and the New York State Department of Motor Vehicles, in connection with an

application submitted by or on behalf of the adoptive child, the adoptive parent(s)' attorney

:

is authorized to deliver a certified copy of this Order of Adoption to such agency directly or to

the adoptive parent, as he or she deems appropriate; and it is further

ORDERED that this order, together with all other papers pertaining to the adoption, shall

be filed and kept as provided in the Domestic Relations Law and shall not be subject to access or

inspections except as provided in this Order or such Law.

ENTER:

[Applicable to orders of the Family Court]:

PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT,

AN APPEAL FROM AN ORDER OF THE FAMILY COURT 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.

Check applicable box:

Order mailed on

Order received in court on