D.R.L.§§ 115, 115-d Form 25 (Conditional Certification as Qualified Adoptive Parent) (8/2010) At a term of the Family Court of the State of New York, held in and for the County of , at , New York on P R E S E N T: Hon. Judge ............................................................................ In the Matter of the Adoption of A Child Whose First Name is Docket No. ORDER (Conditional Certification as a Qualified Adoptive Parent) by Adoptive Parent(s) .............................................................................. The petition of verified the day of , having been filed in this court on the day of , , applying for certification as (a) qualified parent(s) of the adoptive child above-named; and The petition and criminal history check indicating no prior criminal convictions as enumerated in Domestic Relations Law §115-d (3-a), pending child protective investigations, or founded findings of child abuse or neglect; and A report having been filed herein by person as defined in section 115-d of the Domestic Relations Law; and , a disinterested , This Court having determined, based upon the information submitted, that adoption of the above-named child by the Petitioner(s) is in the child's best interests; and Pending completion of any further reports, investigations or inquiries ordered by the Court or required by any other statute or Court rule; American LegalNet, Inc. www.FormsWorkFlow.com Form 25 page 2 Now, therefore, upon consideration of the report and all other relevant and material factors, it is hereby ORDERED that (is) (are) conditionally certified as (a) qualified adoptive parent(s) of the above-named adoptive child and may accept physical custody of such child for the purposes of adoption prior to or contemporaneous with the filing of an adoption petition. NOTICE: THIS ORDER OF CONDITIONAL CERTIFICATION IS VALID UNTIL REPLACED BY AN ORDER OF CERTIFICATION OR BY AN ORDER DENYING CERTIFICATION, BUT IN NO EVENT BEYOND 180 DAYS OF THIS DATE. [Applicable to Family Court Orders]: PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. ENTER ____________________________________ Judge of the Family Court / Surrogate Dated: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com