D.R.L. §§ 115, 115-d (9) Form 26-a (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 PersonExtension of Expired by Certification) Adoptive Parent(s) [Name] that: , being duly sworn, deposes and says 1. I am a disinterested person as defined in section 115-d (4) of the Domestic Relations Law in that (he) (she) has no interest in the outcome of the application of the part (y) (ies) herein for certification as (a) qualified adoptive parent (s). 2. The following fee (s) (have been) (will be) paid to deponent for services rendered in connection with the application for extension of certification: 3. I have read the affidavit and report prepared by and submitted in support of the petition for certification as (a) qualified adoptive parent (s) submitted by petitioner (s) on , . On information and belief, an order granting certification as a qualified adoptive parent (s) was made by the Court, County, on , , and expired on ,. 4. The following Change (s) in circumstances relevant and material to the extension of such certification (has) (have) taken place since the issuance and expiration of the last certification: 5. The source of my knowledge concerning the circumstances of the petitioner's (s') family and household is: [include date, place and duration of personal interview and visit at petitioner's (s') home.] 2001 © American LegalNet, Inc. Form 26-a page 2 Dated: ___________________________________ Affiant (Disinterested Person) ___________________________________ Print or type name Sworn to before me this day of , . Notary Public 2001 © American LegalNet, Inc.