D.R.L. §§ 111(1)(f), 115(4) Form 2-B (Agreement of Adoption 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. AGREEMENT OF ADOPTION (Private-Placement) __________________________________ The under signed petitioning adoptive parent(s) hereby agree(s) to adopt the above-named adoptive child and to treat said child in all respects as (his)(her)(their) own lawful child and to extend and assure to said child all the rights, benefits and privileges incident to such relationship, and to incur and fulfill all the responsibilities of (a) parent(s) with respect to said child. Dated: ______________________________________/______________________________ Adoptive Parent: typed or printed name/ signature ______________________________________/_______________________________ Adoptive Parent: typed or printed name / signature _______________________________________________/_______________________ Adoptive child if over 14: typed or printed name/ signature ______________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney's Address and Telephone number American LegalNet, Inc. www.USCourtForms.com Form 2-B page 2 STATE OF NEW YORK ) ss: ) COUNTY 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 agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement of adoption and consent. _________________________________ Notary Public STATE OF NEW YORK COUNTY ) 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 agreement of adoption and consent. (He)(She) acknowledged to me that (he)(she) executed this agreement of adoption and consent. _________________________________ Notary Public STATE OF NEW YORK COUNTY ) ss: ) On this day of ,, , proven to me by the oath of , an attorney admitted to practice in the State of New York, to be the person(s) who executed the foregoing instrument, personally came before me and acknowledged that (he)(she) executed the same. ____________________________ Judge of the Court American LegalNet, Inc. www.USCourtForms.com