D.R.L. §114 Adoption Form 27-A (Adoption--Petition for Access to Sealed Adoption Records) (9/2006) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ........................................................................................... In the Matter of the Adoption of A Child Whose First Name is (Docket)(File) No. PETITION FOR ACCESS TO SEALED ADOPTION RECORDS ........................................................................................... TO THE FAMILY COURT OF THE COUNTY OF [specify]: The Petitioner respectfully alleges to this Court that: 1. [Check applicable box]: G I am the child who was adopted in the above-entitled proceeding. G My relationship to the above-named child is as follows [specify]: 2. a. I reside at [specify address and telephone number]: b. My mailing address, if different from the above, is [specify]: 3. Upon information and belief, [check applicable box]: G [Applicable where Petitioner is the adoptee]: I was born in [specify city, village or town and State]: on or about [specify date]: A certified copy of my birth certificate is attached. G [Applicable where Petitioner is not the adoptee]: [specify adoptee’s name]: was born in [specify city, village or town and State]: on or about [specify date]: A certified copy of the birth certificate is attached. 4. Upon information and belief, [check applicable box]: G [Applicable where Petitioner is the adoptee]: I was adopted pursuant to court order in the [specify county and court, if known]: G [Applicable where Petitioner is not the adoptee]: [specify adoptee’s name]: was adopted pursuant to court order in the [specify county and court, if known]: 5. A request for information G has G has not been made of the Adoption Information Registry. [Direct inquiries to: NYS Department of Health , Adoption Information Registry, P.O. Box 2602, Albany, New York 12220- 2602, (518)474-9600] 6. The names, dates of death, permanent addresses of the adoptive parents, if living, and the adoptee’s birth name, if known, are as follows [specify]: 7. [Check applicable box(es)]: G I am requesting access to sealed adoption records on medical grounds for the following American LegalNet, Inc. www.FormsWorkflow.com Adoption Form 27-A Page 2 reasons [specify]: [NOTE: If your request is based on medical grounds, you must attach a medical certification from a physician licensed to practice medicine in the State of New York addressing a serious physical or mental illness. Such certification shall identify the information required to address the illness.] G I am requesting access to sealed adoption records for good cause, other than medical, for the following reasons [specify]: G [Applicable to Native-American individuals 18 years of age and older]: I am requesting access to sealed adoption records, including information about my birth parents’ tribal affiliation(s), if any, and other information necessary to protect any rights flowing from such tribal affiliations. 8. No previous application has been made for the relief requested herein except as follows: [Enter “NONE”, or specify]: I understand that the Court may appoint a law guardian for the purpose of reviewing the file and determining whether the information being sought is in the file and to undertake such other and further instructions that the Court may require. WHEREFORE, for the reasons stated above, I respectfully request access to the sealed adoption records and information sought above and for such other and further relief as this Court deems just and proper. Dated: , . ______________________________________ Petitioner’s signature ______________________________________ Petitioner: Print or type name ______________________________________ Attorney’ signature, if any ______________________________________ ______________________________________ Attorney’s Address and Telephone number VERIFICATION STATE OF NEW YORK COUNTY OF ) :ss.: ) being duly sworn, says that (he)(she) is the Petitioner(s) in the above-named proceeding and that the foregoing petition is true to (his)(her) own knowledge, except as to matters stated to be alleged on information and belief and as to those matters (he)(she) believe(s) them to be true. ______________________________________/________________________ Petitioner: typed or printed name/ Signature Sworn to before me this day of , . __________________________ (Deputy)Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkflow.com