D.R.L. §§ 111-a(1), 112 Form 1-A (Adoption Petition-Agency) (9/2006) SURROGATE'S 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 ADOPTION (Agency) ................................................................................................... The Petitioner(s) respectfully allege(s) to this Court that [Delete inapplicable provisions]: 1. Petitioning adoptive parent [specify name]: a. resides at [specify address, including county]: b. is of full age, having been born on [specify date of birth]: c. is G unmarried G married to [specify name]: and living together; G married to [specify name]: and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded; G married to [specify name]: apart for at least three years prior to commencement of the proceeding); d. is of the following religious faith, if any [specify]: e. is engaged in the following occupation [specify]: and earns $ in approximate annual income [delete if inapplicable]: of which $ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child. 2. Petitioning adoptive parent [specify name]: a. resides at [specify address, including county]: b. is of full age, having been born on [specify date of birth]: c. is G unmarried G married to [specify name]: and living together; and living separate and G married to [specify name]: and living separate and apart pursuant to a decree or judgment of separation or pursuant to a separation agreement subscribed by the parties thereto and acknowledged or proved in the form required to entitle a deed to be recorded; American LegalNet, Inc. www.FormsWorkflow.com Adoption Form 1-A G married to [specify name]: apart for at least three years prior to commencement of the proceeding); d. is of the following religious faith [specify]: Page 2 and living separate and e. is engaged in the following occupation [specify]: and earns $ in approximate annual income [delete if inapplicable]: of which $ is support and maintenance to be received from the Commissioner of Social Services on behalf of the adoptive child. 3. Upon information and belief, the adoptive child, whose first name is [specify]: , was born on , , at and the religious faith of such child is [specify]: . 4. Upon information and belief, there will be annexed to this petition a schedule verified by a duly constituted official of [specify agency]: , an authorized agency, as required by section 112(3)of the Domestic Relations Law, concerning the adoptive child who is the subject of this proceeding. 5. The following is information, as nearly as can be ascertained, concerning the birth or legal parents of the adoptive child: (a) Age and date of birth Parent [specify name]: Parent [specify name]: (b) Heritage (specify nationality, ethnic background, race) Parent [specify name]: Parent [specify name]: (c) Religious faith, if any Parent [specify name]: Parent [specify name]: (d) Education [specify number of years of school or degrees completed at time of birth of adoptive child]: Parent [specify name]: Parent [specify name]: (e) General physical appearance at time of birth of adoptive child [specify height, weight, color of hair, eyes, skin]: Parent [type name]: Ht:_________ Wt:____________ Hair Color: ___________ Eye Color: _______ Skin Color: __________ Parent [type name]: Ht:_________ Wt:____________ Hair Color: ___________ Eye Color: _______ Skin Color: __________ American LegalNet, Inc. www.FormsWorkflow.com Adoption Form 1-A Page 3 (f) Annex Form 1-D which provides health and medical history of birth parents at time of birth of adoptive child, including conditions or diseases believed to be hereditary and any drugs or medication taken during pregnancy by child's mother. (g) Specify any other information which may be a factor influencing the adoptive child's present or future well-being, including talents, hobbies and special interests of parents: [attach separate sheet if necessary] 6. The subject child is is not a Native-American child, who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§ 1901-1963). If so, the following have been notified [check applicable box(es)]: parent/custodian [specify name and give notification date]: tribe/nation [specify name and give notification date]: United States Secretary of the Interior [give notification date]: 7. The manner in which the adoptive parent(s) obtained the adoptive child is as follows: [Delete if inapplicable]: 8. The placement is subject to the provisions of section(s) G374-a G 382 of the Social Services Law and the provisions of such sections have been complied with. The original approval signed by the Administrator of the Interstate Compact on the placement of Children is attached hereto. 9. The adoptive child resided with the adoptive parent(s) from [specify date]: . 10. Other persons living in the household are [specify names and dates of birth]: . 11. 12. adopted. The name by which the adoptive child is to be known is: Upon information and belief, the adoptive child Ghas Ghas not been previously 13. To the best of Petitioner(s)' information and belief, there are no persons other than those mentioned herein or in the verified schedule annexed hereto who are entitled, pursuant to Sections 111(3) and 111-a of the Domestic Relations Law, to notice of this proceeding (except): Name: Last known address: . Name: Last known address: . Name Last known address: . 14 (a). The adoptive parent(s) G(has)(have) G (has)(have) no knowledge that the child or an adoptive parent is the subject of an indicated report, or is another person named in an indicated report of child abuse or maltreatment, as such terms are defined in section 412 of the Social Services Law, or has been the subject of or the respondent in a child protective proceeding which resulted in an order American LegalNet, Inc. www.FormsWorkflow.com Relationship: Relationship: Relationship: Adoption Form 1-A finding that the child is an abused or neglected child. Page 4 (b)[Check applicable box(es)]: Upon information and belief, G Neither the adoptive parent(s) nor any other adult over the age of 18 residing in the household