Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Extrajudicial Consent (Birth Or Legal Parent - Private Placement) Form. This is a New York form and can be use in Adoption Statewide.
Loading PDF...
Tags: Extrajudicial Consent (Birth Or Legal Parent - Private Placement), 2-G, New York Statewide, Adoption
D.R.L. §§ 115,115-b
COURT OF THE STATE OF NEW YORK
COUNTY OF
___________________________________________
In the Matter of the Adoption of
A Child whose First Name is
Form 2-G
(Extrajudicial Consent -Birth or Legal
Parent -- Private-placement)
9/2009
(Docket)(File) No.
EXTRAJUDICIAL CONSENT
(Birth or Legal Parent -Private-Placement)
__________________________________________
THIS CONSENT MAY BE REVOKED WITHIN 45 DAYS OF THE
EXECUTION OF THIS DOCUMENT. IF THE CONSENT IS NOT
REVOKED WITHIN SAID 45 DAYS, NO PROCEEDING MAY BE
MAINTAINED BY THE PARENT FOR THE RETURN OF THE
CUSTODY OF THE CHILD. THE REVOCATION MUST BE IN
WRITING AND RECEIVED BY THE COURT WHERE THE
ADOPTION PROCEEDING IS TO BE COMMENCED WITHIN 45
DAYS OF THE EXECUTION OF THE CONSENT. THE NAME
AND ADDRESS OF THE COURT IN WHICH THE ADOPTION
PROCEEDING HAS BEEN OR IS TO BE COMMENCED IS:
[specify name and address of court]:
IF THE ADOPTIVE PARENTS CONTEST THE REVOCATION,
TIMELY NOTICE OF REVOCATION WILL NOT NECESSARILY
RESULT IN THE RETURN OF THE CHILD TO THE PARENT,
AND THE RIGHT OF THE PARENT TO THE CUSTODY OF THE
CHILD WILL NOT BE SUPERIOR TO THOSE OF THE
ADOPTIVE PARENTS. A HEARING BEFORE A JUDGE WILL
BE REQUIRED TO DETERMINE: (1) WHETHER THE NOTICE
OF REVOCATION WAS TIMELY AND PROPERLY GIVEN; AND
IF NECESSARY, (2) WHETHER THE BEST INTERESTS OF THE
CHILD WILL BE SERVED: (A) BY RETURNING CUSTODY OF
THE CHILD TO THE PARENT; OR (B) BY CONTINUING THE
ADOPTION PROCEEDING COMMENCED BY THE ADOPTIVE
PARENTS; OR (C) BY DISPOSITION OTHER THAN ADOPTION
BY THE ADOPTIVE PARENTS; OR (D) BY PLACEMENT OF
American LegalNet, Inc.
www.FormsWorkFlow.com
Form 2g Page 2
THE CHILD WITH AN AUTHORIZED AGENCY. IF ANY SUCH
DETERMINATION IS MADE, THE COURT WILL MAKE SUCH
DISPOSITION OF THE CUSTODY OF THE CHILD AS WILL
BEST SERVE THE INTERESTS OF THE CHILD.
THE PARENT HAS THE RIGHT TO LEGAL REPRESENTATION
OF THE PARENT'S OWN CHOOSING, THE RIGHT TO
SUPPORTIVE COUNSELING AND MAY HAVE THE RIGHT TO
HAVE THE COURT APPOINT AN ATTORNEY PURSUANT TO
SECTION 262 OF THE FAMILY COURT ACT, SECTION 407 OF
THE SURROGATE'S COURT PROCEDURE ACT, OR SECTION
35 OF THE JUDICIARY LAW.
1. I , [specify name]:
, residing at
, am the Q birth Qlegal parent of [specify first name of
. I do hereby consent to the adoption of my Qdaughter Qson, who was , born on
by [specify name]:
adoptive parent(s).
child]:
[specify date]:
2. The full name and last known address of the other Qbirth Qlegal parent of the adoptive child are
[optional]:
3. I Qhave Q have not been represented by counsel. If represented, state counsel's name, address and
telephone number:
4. I [print name of consenting parent]:
this ___ day of ________, ____, have received a copy of this consent.
Date:
___________________________________/__________________________________
Q birth Qlegal parent: type or print name/ signature
______________________________________/________________________________
Attorney, if any: type or print name/
signature
______________________________________________________________________
Attorney’s Address and Telephone number
STATE OF NEW YORK )
: ss.:
COUNTY OF
)
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 extrajudicial surrender. (He)(She) acknowledged to me that (he)(she)
executed this surrender.
_____________________________
Notary Public
American LegalNet, Inc.
www.FormsWorkFlow.com
