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Fill and Sign the This Form Must Be Submitted in Cases Where the Adoption

Fill and Sign the This Form Must Be Submitted in Cases Where the Adoption

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D.R.L. §113 Adoption Form 1-E[This form must be submitted (Affirmation Regarding Venue)in cases where the adoption petition was filed before (9/2006)a judge other than the judge who heard the most recent Family Court proceeding] FAMILY COURT OF THE STATE OF NEW YORKCOUNTY OF.........................................................................................In the Matter of the Adoption of Docket No.A Child Whose First Name Is: AFFIRMATION REGARDING VENUE .....................................................................................I , [specify name]: ,, an attorneyduly admitted to practice law in the State of New York, affirm the following:1. I represent [specify]:, the prospective adoptiveparents in the above-entitled proceeding regarding the adoption of [specify child’s first name]: 2. Upon information and belief, according to [specify agency having custody orguardianship of child or other source of information]:the child was freed for adoption as follows [check applicable box(es)]:a. The child’s birth mother:G surrendered her parental rights in a Gjudicial surrender executed before Judge [specify]: in Family Court,[specify county]: on [specify date]: in Docket # [specify]: Gextra-judicial surrender approved by Judge [specify]: in Family Court,[specify county]: on [specify date]: in Docket # [specify]:G had her parental rights terminated by order of Judge [specify]: in FamilyCourt, [specify county]: on [specify date]: in Docket # [specify]:G is unknown. G is deceased.b. The child’s birth father or any other individual entitled to consent to the adoption:G surrendered his parental rights in a Gjudicial surrender executed before Judge [specify]: in Family Court,[specify county]: on [specify date]: in Docket # [specify]: Gextra-judicial surrender approved by Judge [specify]: in Family Court,[specify county]: on [specify date]: in Docket # [specify]:G had his parental rights terminated by order of Judge [specify]: in FamilyCourt, [specify county]: on [specify date]:in Docket # [specify]: G is unknown. G is deceased. Adoption Form I-E Page 23. Upon information and belief, according to [specify agency having custody orguardianship of child or other source of information]:the child’s most recent permanency hearing was held before [specify judge or referee]in Family Court, [specify county]: , on [specify date]: 4. This adoption proceeding has been filed before this Court for the following reasons[check applicable box(es) and explain]:G This Court is more familiar with the facts and circumstances regarding permanencyplanning for, and the needs and best interests of, this child, because [specify]:G The child’s law guardian [specify]: is able to continue to representthe child in this proceeding.G The prospective adoptive parents reside in [specify county]and would find it inconvenient to travel to the Family Court in [specify county]:G This Court will be able to proceed in this matter more expeditiously because [specify]:G Other [specify]:WHEREFORE, for the reasons stated above, I am requesting that this Court retainjurisdiction over this adoption proceeding.__________________________________________ Signature of Affirmant__________________________________________ Affirmant’s Name (print or type)______________________________________________________________________________________________________________________________ Affirmant’s Address and Telephone Number

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