D.R.L. §§ 109(6), 111(1)(f), 115(6) Form 2-E (Affidavit and Consent - Person Having Custody Private-Placement) 8/2002 COURT OF THE STATE OF NEW YORK COUNTY OF ____________________________________ In the Matter of the Adoption of A Child whose First Name is (Docket)(File) No. AFFIDAVIT AND CONSENT OF PERSON HAVING LAWFUL CUSTODY (Other than Birth or Legal ParentPrivate-Placement) _____________________________________ STATE OF NEW YORK COUNTY OF ) ss.: ) (I) (we) [specify name(s)]: (and being duly sworn, depose(s) and say(s): Deponent(s) reside(s) at ), and (is)(are) the person(s) having lawful custody of the above-named adoptive child in that: [recite facts showing how lawful custody was obtained] Deponent(s) hereby consent(s) to said child's adoption by the petitioning adoptive parent(s) ). ________________________________ ________________________________ (and American LegalNet, Inc. www.USCourtForms.com Form 2-E page 2 ______________________________________/______________________________ Affiant (Person Having Legal Custody) typed or printed name/ signature ______________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney's Address and Telephone number STATE OF NEW YORK COUNTY OF ) ss.: ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this affidavit and consent. (He)(She) acknowledged to me that (he)(she) executed this affidavit and consent. _______________________________ Notary Public STATE OF NEW YORK COUNTY OF ) ss.: ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this affidavit and consent. (He)(She) acknowledged to me that (he)(she) executed this affidavit and consent. _______________________________ Notary Public American LegalNet, Inc. www.USCourtForms.com