D.R.L. § 111(1) (a) Form 2-D (Consent of Child 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. CONSENT OF CHILD OVER 14 (Private-Placement) ................................................................................................ The undersigned adoptive child, who is years old, having been born on hereby consents to (his) (her) adoption by petitioning adoptive parent(s) in the above-entitled proceeding. Dated: ______________________________________ Child ______________________________________/______________________________ 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 , ) , the American LegalNet, Inc. www.USCourtForms.com Form 2-D page 2 STATE OF NEW YORK COUNTY OF ) 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 consent. (He)(She) acknowledged to me that (he)(she) executed this consent. _______________________________________ Notary Public STATE OF NEW YORK COUNTY OF ) ss.: ) day of , , before me personally came proven to me by the oath of an attorney admitted to practice in the State of New York to be the person described in and who executed the foregoing instrument and duly acknowledged that executed the same. On this ___________________________________ Judge of the Court American LegalNet, Inc. www.USCourtForms.com