D.R.L. §112-b Adoption Form 14-A (Order of Incorporation of Post-adoption Contact Agreement - Agency Adoption) (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 , . , PRESENT: Hon. Judge ................................................................ In the Matter of the Adoption of A Child Whose First Name Is Docket No. (Docket) (File) ORDER OF INCORPORATION OF POST-ADOPTION CONTACT AGREEMENT (Agency Adoption) ................................................................ A Petition having been presented to this Court regarding the adoption of the above named child, and the Petition having included a surrender/consent to adopt signed by the following birth parent(s)[specify]: before Judge [specify]: of [specify Court and County]: on [specify date]: And the Court that approved the execution of the surrender having also approved the attached Post-adoption Contact Agreement signed and agreed to by the following [specify]: as being in the best interests of the child;1 And this Court having issued an Order, Docket No. [specify]: for the child to be adopted, it is hereby ORDERED that the terms and conditions of the attached Post-adoption Contact Agreement are hereby incorporated into the Adoption order such that the terms and conditions survive the adoption order and are subject to proceedings under DRL 112-b; and it is further 1 A true copy of the approved Post-adoption Contact Agreement must be attached to this Order. American LegalNet, Inc. www.FormsWorkFlow.com Adoption Form 14-A Page 2 ORDERED that the [check applicable box]: Q Clerk of Court Q Other [specify]: shall provide a copy of this incorporation order and the attached Postadoption Contact Agreement to all those persons and their attorneys who are listed above as those who signed and agreed to the terms and conditions of the Post-adoption Contact Agreement. And it is further ORDERED that: ENTER ______________________________ G Judge of the Family Court G Surrogate 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. 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