OCFS-4156 (Rev. 06/2007) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES SCR USE: BATCH# ORDER OF ADOPTION FAMILY COURT/SURROGATE COURT REQUEST FORM RESOURCE ID #: COURT LIAISON AREA CODE/PHONE # ( DOCKET FILE # COURT NAME AND ADDRESS ) - ZIP CODE Section 112 of the Domestic Relations Law, as amended by Chapter 164 of the laws of 1991, requires that an inquiry be made of the New York Statewide Register of Child Abuse and Maltreatment (SCR) to determine if the adoptive parent(s) are the subject of an indicated child abuse or maltreatment report. Date of Request: TO BE FILLED OUT BY ADOPTIVE PARENT(S) LAST NAME (father) ALIAS NAME(S) CURRENT ADDRESS: STREET PRIOR ADDRESS(ES) (STREET) FOR THE LAST 28 YEARS CITY CITY CITY CITY CITY CITY CITY LAST NAME (mother) ALIAS NAME(S) CURRENT ADDRESS: STREET PRIOR ADDRESS(ES) (STREET) FOR THE LAST 28 YEARS CITY CITY CITY CITY CITY CITY CITY STATE STATE STATE STATE STATE STATE STATE ZIP ZIP ZIP ZIP ZIP ZIP ZIP FROM FROM FROM FROM FROM FROM FROM TO TO TO TO TO TO TO FIRST NAME STATE STATE STATE STATE STATE STATE STATE MI ZIP ZIP ZIP ZIP ZIP ZIP ZIP SEX M F FROM FROM FROM FROM FROM FROM FROM TO TO TO TO TO TO TO FIRST NAME MI SEX M F DATE OF BIRTH DATE OF BIRTH MEMBERS OF ADOPTIVE PARENT(S) HOUSEHOLD LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS LAST NAME & MAIDEN/ALIAS FIRST NAME FIRST NAME FIRST NAME FIRST NAME FIRST NAME FIRST NAME FIRST NAME MI MI MI MI MI MI MI SEX M SEX M SEX M SEX M SEX M SEX M SEX M DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F American LegalNet, Inc. www.FormsWorkFlow.com OCFS-4156 (Rev. 02/2009) REVERSE COURT INSTRUCTIONS RESOURCE ID # Record your Resource ID # as appropriate. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us Record your Court Docket File # as appropriate. Record name of Court Liaison. Record the Court processing date. DOCKET/FILE #: COURT LIAISON: DATE OF REQUEST: Order of Adoption Family Court/Surrogate Court forms are to be sent to: The New York Statewide Central Register Of Child Abuse and Maltreatment P.O. Box 4480, Attn: Service Center Unit Albany, N.Y. 12204-0480 TO ORDER MORE FORMS: Please access the Request for Forms and Publications form, (OCFS-4627) from the Internet: http://www.ocfs.state.ny.us/main/forms/management_services/ Mail your completed Request for Forms and Publications, (OCFS-4627) to the Office of Children and Family Services, Forms Management Unit, Resource Distribution Center, 11, Fourth Ave, Rensselaer, NY 12144-2629. If you have difficulty accessing the form from the web-site, you can call The Forms Hot Line at: 518-473-0971. American LegalNet, Inc. www.FormsWorkFlow.com