Petition For Adoption (Private Placement) {1-C}

D.R.L.§§ 111, 111-a, 112, 115 S.C.P.A. § 1725(1) Form 1-C (Petition-Private Placement) 9/2006 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................ In the Matter of Adoption of A Child Whose First Name Is Docket No. PETITION FOR ADOPTION (Private-Placement) .......................................................... The Petitioner(s) respectfully allege(s) to this Court that : 1. Petitioning adoptive parent [specify name]: a. resides at [specify address, including county]: b. is of full age, having been born on [specify date of birth]: unmarried; married to and living together; married to and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded; married to and living separate and apart for at least three years prior to commencement of the proceeding; d. is of the following religious faith, if any: e. is engaged in the following occupation [specify]: and earns $ of which $ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child). 2. Petitioning adoptive parent [specify name]: a. resides at [specify address, including county]: c. is American LegalNet, Inc. www.FormsWorkflow.com Form 1-C page 2 b. is of full age, having been born on [specify date of birth]: unmarried; married to and living together; married to and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded); married to and living separate and apart for at least three years prior to commencement of the proceeding); c. is d. is of the following religious faith, if any: e. is engaged in the following occupation and earns $ in approximate annual income of which $ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child). 3. he full name, date and place of birth of the adoptive child is T [attach certified copy of birth certificate] 4. Upon information and belief, the religious faith of the adoptive child, if any, is: 5. The following is information, as nearly as can be ascertained, concerning the birth or legal parents of the adoptive child: (a) Full name and last known address Parent (specify full name and address, if known): Parent (specify full name and address, if known): (b) Age and date of birth American LegalNet, Inc. www.FormsWorkflow.com Form 1-C page 3 Parent (specify name): Parent (specify name): (c) Heritage (specify nationality, ethnic background, race) Parent (specify name): Parent (specify name): (d) Religious faith, if any Parent (specify name): Parent (specify name): (e) Education (specify number of years of school or degrees completed at time of birth of adoptive child) Parent (specify name):___________________________________ Parent (specify name):___________________________________ (f) General physical appearance at time of birth of adoptive child (height, weight, color of hair, eyes, skin) Parent (specify name): Ht:____________ Wt:________________ Hair Color: ____________ Eye Color: __________ Skin Color: ____________ Parent (specify name): Ht:____________ Wt:________________ Hair Color: ____________ Eye Color: __________ Skin Color: ____________ (g) Annex Form 1-D which provides health and medical history at time of birth of adoptive child, including conditions or diseases believed to be hereditary and any drugs or medication taken during pregnancy by child's mother. (h) Any other information which may be a factor influencing the adoptive child's present or future well-being, including talents, hobbies and special interests of parents: [attach separate sheet if necessary] 6. The manner in which the adoptive parent(s) obtained the adoptive child is as follows: 7. he adoptive child resided with the adoptive parent(s) from [indicate date]: T 8. Other persons living in the household are: [Specify names and dates of birth]: 9. The name by which the adoptive child is to be known is: American LegalNet, Inc. www.FormsWorkflow.com Form 1-C page 4 Upon information and belief, the adoptive child has not been previously adopted. 10. 11. The full name(s) and address(es) of any person(s) having lawful custody of the adoptive child, if known (is)(are) 12. On information and belief, pursuant to Domestic Relations Law §111, (a) the consent of the birth or legal parent of the adoptive child is attached hereto. (b) the consent of the birth or legal parent of the adoptive child is attached hereto. (c) the consent(s) of the above-named person(s) having lawful custody of the adoptive child is attached hereto. (d) The consent(s) of other person(s)[specify name(s)]: is attached hereto. 13(a) The consent of the birth or legal parent [specify name:] was executed pursuant to section 115-b(3) of the Domestic Relations Law on ______________, _____; the 45th day after execution of the consent is _______________, _____. (b) The consent of the birth or legal parent [specify name:] was executed pursuant to Section 115-b(3) of the Domestic Relations Law on _______________, _____; the 45th day after execution of the consent is ______________, ______.) 14. This court is not the court named in the consent(s) of the parent(s) of the adoptive child, attached hereto, as the court in which the adoption proceeding will be commenced, but more than 45 days have elapsed since the date of execution of said consent(s) and, on information and belief, no written notice of revocation has been received by that court. 15. That on information and belief said minor child has a general guardian. [state nature, date and place of appointment]: American LegalNet, Inc. www.FormsWorkflow.com Form 1-C page 5 16. To the best of the Petitioner(s)' information and belief, there are no persons other than those mentioned herein or in the verified scheduled annexed hereto who are entitled, pursuant to Domestic Relation Law §111(3) and 111-a, to notice of this proceeding (except) Name: Last known address: Relationship: Name Last known address: Name Last known address: Relationship: Relationship: 17. The child is is not under the jurisdiction of the Family Court. If so, this petition has has not been filed in the Court that exercised jurisdiction over the most rec