D.R.L §§ 115, 115-d. Form 23 (Certification as Qualified Adoptive Parent) 9/99 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 REPORT (Disinterested Person-Certification Proceeding) (Private-Placement) by Adoptive Parent State of New York County of ) :ss.. ) being duly sworn deposes and says that: 1. (He)(She) is a disinterested person as such person is defined in section 115-d of the Domestic Relations Law in that: and has no interest in the out come of the application of the part(y)(ies) herein for certification as qualified adoptive apparent(s); 2. The following fee(s) (have been) (will be) paid to deponent for services rendered in connection with the pre-placement investigation performed in connection with this certification proceeding: ; 3. The following is deponent's report of (his)(her) investigation into the truth and accuracy of the allegations set forth in the petition of , as qualified adoptive parents in the proceeding for certification and (deponent's investigation of the various factors relevant to the suitability of the petitioners as qualified adoptive parents: American LegalNet, Inc. www.USCourtForms.com Form 23 page 2 (a) Date, place and duration of personal interview and visit at petitioners home: (b) Report: (c) other facts relating to familial, social, religious, emotional and financial circumstances of petitioners relevant to certification as a qualified adoptive parent(s). Dated: ___________________________________ Affiant (Disinterested Person) ___________________________________ Print or type name Sworn to before me this day of , . Notary Public American LegalNet, Inc. www.USCourtForms.com