D.R.L. §114 Form 15-A page 1 Form 15-A (Application for Certified Copy of Adoption Order (Before sealing of records) 9/99 COURT OF THE STATE OF NEW YORK COUNTY OF In the matter of the Adoption of (Docket)(File) No . APPLICATION FOR CERTIFIED COPY OF ADOPTION ORDER(Before sealing of records) A Minor of the Age of years The undersigned applicants) respectfully show(s) that: 1. The applicant(s) reside(s) at County of State of (and) (and) (respectively) in the . 2. On or about the day of , , an order was made by the Honorable Judge of the Court of County, State of New York, approving the adoption of the above-named child by , and thereafter, said order was duly filed in the office of the Clerk of the Court of the County of . 3. It is necessary for the applicant (s) to obtain a certified copy of said order approving the adoption because of the following facts and circumstances: WHEREFORE, applicant (s) pray (s) that the Court make an order directing the Clerk of the Court of the County of to prepare, certify and deliver to the applicant a copy of the original order of adoption granted herein, and for such other and further relief as to the Court may be just and proper. Applicant 2001 © American LegalNet, Inc. Form 15-A page 2 Applicant ___________________________________ Petitioner ___________________________________ Print or type name ___________________________________ Signature of Attorney, if any ___________________________________ Attorney's Name (Print or Type) ___________________________________ ___________________________________ ___________________________________ Attorney's Address and Telephone Number VERIFICATION STATE OF NEW YORK COUNTY OF ) )ss.: ) being duly sworn, say(s) that (he)(she)(they)(is)(are) the applicants above named; that (he)(she)(they)(have)(has) read the foregoing application and the same is true to (his)(her) (their) knowledge except as to matters therein stated to be alleged on information and belief and as to those matters (he)(she)(they) believers) it to be true. Applicant Applicant Subscribed and sworn to before me this day of (Deputy) Clerk of the Court 2001 © American LegalNet, Inc. Form 15-A page 3 Notary Public 2001 © American LegalNet, Inc.