D.R.L. §112 Adoption Form 10-C (Affidavit Regarding Status of Appeal ­ Agency Adoption) (8/2010) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Adoption of A Child Whose First Name Is: ..................................................................................... STATE OF NEW YORK ) )ss.: COUNTY OF ) Docket No. AFFIDAVIT REGARDING STATUS OF APPEAL1 I , [specify name]: , , an attorney duly admitted to practice law in the State of New York, swear the following to be true under the penalties of perjury: 1. I represented [specify authorized agency]: in the following proceeding(s) that resulted in the above-named child being freed for adoption [specify termination of parental rights and/or surrender proceeding(s)]: 2. The parental rights of the child's birth mother were terminated as a result of [check applicable box(es)]: 9 an order of disposition in a termination of parental rights proceeding, dated [specify]: which was served upon the: 9 attorney for the child 9 counsel for the mother 9 mother, if self-represented; 9 other parties [specify]: [Check box if applicable]: 9 The order was not served upon the mother, because she never appeared in the proceeding. This order has not been reversed, modified or vacated and [check applicable box(es)]: 9 a notice of appeal has not been filed and the time to file a notice 9 has 9has not lapsed. 9 a notice of appeal was filed and: 9 the appeal was dismissed as it was not perfected. 9 the appeal was not perfected and the time to perfect 9 has 9has not lapsed. 9 the appeal was perfected and has been disposed of as follows [specify]: This form must be filed for all agency adoptions involving children freed for adoption by termination of parental rights or surrender and should be completed by the attorney representing the agency in those proceedings. 1 American LegalNet, Inc. www.FormsWorkFlow.com Adoption Form 10-C Page 2 and 9 is 9 is not the subject of any further appeal or proceeding on remand pending in any Court; 9 a surrender of the child, dated [specify]: The surrender has not been revoked or vacated and [check applicable box(es)]: 9 it is not the subject of revocation proceedings. 9 revocation proceedings were brought but were disposed of as follows [specify]: 9 a notice of appeal has not been filed and the time to file a notice 9 has 9has not lapsed. 9 a notice of appeal was filed and: 9 the appeal was dismissed as it was not perfected. 9 the appeal was not perfected and the time to perfect 9 has 9has not lapsed. 9 the appeal was perfected and has been disposed of as follows [specify]: and 9 is 9 is not the subject of any further appeal or proceeding on remand pending in any Court; 3. The parental rights of the child's birth father or any other individual entitled to consent to the adoption were terminated as a result of [check applicable box(es)]: 9 an order of disposition in a termination of parental rights proceeding, dated [specify]: which was served upon the: 9 attorney for the child 9 counsel for the father 9 father, if self-represented; and 9 other parties [specify]: [Check box if applicable]: 9 The order was not served upon the father because he never appeared in the proceeding. This order has not been reversed, modified or vacated and [check applicable box(es)]: 9 a notice of appeal has not been filed and the time to file a notice 9 has 9has not lapsed. 9 a notice of appeal was filed and: 9 the appeal was dismissed as it was not perfected. 9 the appeal was not perfected and the time to perfect 9 has 9has not lapsed. 9 the appeal was perfected and has been disposed of as follows [specify]: and 9 is 9 is not the subject of any further appeal or proceeding on remand pending in any Court; 9 a surrender of the child, dated [specify]: The surrender has not been revoked or vacated and [check applicable box(es)]: 9 it is not the subject of revocation proceedings. 9 revocation proceedings were brought but were disposed of as follows [specify]: 9 a notice of appeal has not been filed and the time to file a notice 9 has 9has not lapsed. 9 a notice of appeal was filed and: 9 the appeal was dismissed as it was not perfected. American LegalNet, Inc. www.FormsWorkFlow.com Form SURR-3 Page 3 9 the appeal was not perfected and the time to perfect 9 has 9has not lapsed. 9 the appeal was perfected and has been disposed of as follows [specify]: and 9 is 9 is not the subject of any further appeal or proceeding on remand pending in any Court; __________________________________________ Signature of Attorney, if any __________________________________________ Attorney's Name (print or type) __________________________________________ __________________________________________ __________________________________________ Attorney's Address and Telephone Number Sworn to before me this day of _______________________ Clerk of Court (Deputy) (Clerk of the Court) (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com