Fill and Sign the Supplemental Affidavit Form

22 NYCRR 205.53(c) Form 10-B (Supplemental Affidavit Private-Placement) 9/99 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of the Adoption of (Docket)(File) No. A child whose First Name is SUPPLEMENTAL AFFIDAVIT (Private-Placement) STATE OF NEW YORK) ss: COUNTY) (and ) being duly sworn, depose(s) and say(s): 1. Deponent(s) (is) (are) the same person(s) who on filed in this Court a petition for adoption of the above-named adoptive child. 2. Deponent(s) (is) (are) over the age of twenty-one years, citizen(s) of the United States, and (unmarried)(married and living together) (married and living apart). 3. The post-office addresses, place(s) of residence and home telephone number(s) of petitioner(s) (is) (are) Petitioner (specify name): Petitioner (specify name): 4. Petitioner(s) hereby state(s) that there has been no change of circumstances whatsoever since the filing of said original petition, dated , except as follows: Form 10-B page 2 Date: ______________________________________/______________________________ Adoptive Parent: typed or printed name/ signature ______________________________________/_______________________________ Adoptive Parent: typed or printed name / signature _______________________________________________/_______________________ Adoptive child if over 18: typed or printed name/ signature ______________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney’s Address and Telephone number Sworn to before this day of . ______________________________ Judge of the Court