D.R.L. §§116 (2) Form 12 (Order Removing Child From Adoptive Home) 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 (Dock No.et)( Docket ORDER REMOVING CHILD FROM ADOPTIVE HOME _____________________________________ ,the adoptive child above named having been placed for adoption on or about , , with the petitioner(s) herein, and a petition having been duly filed in this Court praying for an order of adoption pursuant to section 116 of the Domestic Relations Law; and This Court having on the day of , , issued an order of investigation designating to examine into the allegations set forth in the petition and to make a written report of the investigation; and the investigator having duly made and submitted a written report of investigation dated , ; and it appearing from the report that good cause exists for the removal of the adoptive child from the home of said petitioner(s); and The petitioner(s) having been ordered to show cause why the adoptive child should not be removed from the home of said petitioner(s); and due notice of this proceeding having been given to (and ); and the Court having taken proof of the facts shown by the investigations and the Court being satisfied that the welfare of the adoptive child requires that (he)(she) be removed from the home of the petitioner(s); Now, therefore, it is hereby ORDERED that ,the adoptive child, is removed from the home of American LegalNet, Inc. www.FormsWorkFlow.com Adoption Form 12 (and ) and is Q transferred to the Family Court Q returned to Q placed with [specify ]: );(and it is further) ORDERED that a copy of this order be served upon , an authorized agency.) 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. Page 2 ENTER _____________________________________ _______ JUDGE OF THE FAMILYCOURT ) (SURROGATE.) (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