D.R.L.§115-c; S.C.P.A.§1725 Form 21-A (Petition for Temporary Guardianship) 9/2008 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ......................................................................................... In the Matter of the Temporary Guardianship of A Child Whose First Name is (Docket)(File)No. Petition for Temporary Guardianship .......................................................................................... The Petitioner(s) respectfully allege(s) to the Court that: 1. Physical custody of [specify child's first and last name]: a child born on , was transferred to [specify]: and for the purposes of adoption on the day of , by [specify]: , the child's parent(s) guardian(s), and the requirements for certification of [specify]: as qualified adoptive parents herein were [check applicable box]: complied with duly waived by order of the , Court, County of dated , 2. The residence and telephone number of Petitioner(s) are: 3. The full name(s) and addresse(s) of the birth parent(s) of the child are: . 4. The anticipated name of the child subsequent to adoption will be: . 5. The anticipated residence of the child subsequent to adoption will be: American LegalNet, Inc. www.FormsWorkflow.com Form 21-A page 2 6. A consent to the adoption of the child was duly executed pursuant to section 115-b of the Domestic Relations Law on , . A copy of the consent to the adoption is annexed hereto. 7. The child will be residing with Petitioner(s), and a petition for adoption of the child by Petitioner(s) will be filed in the Court of the County of , State of New York, within 45 days of the execution of the consent to adoption of the child. 8. No previous petition has been filed or application made to any court or judge for the relief sought herein (except)[include any proceedings dismissed or withdrawn]: WHEREFORE, Petitioner(s) request(s) an order granting temporary guardianship of the child to Petitioner(s). Petitioner(s) ________________________________ Applicant ________________________________ Print or type name ________________________________ Signature of Attorney, if any ________________________________ Attorney's Name (Print or Type) ________________________________ ________________________________ ________________________________ Attorney's Address and Telephone Number Dated: American LegalNet, Inc. www.FormsWorkflow.com Form 21-A page 3 VERIFICATION STATE OF NEW YORK COUNTY OF ) )ss.: ) , being duly sworn, says that (he) (she) (they) (is)(are) the Petitioner(s) in the above-named proceeding and that the foregoing petition is true to (his) (her) (their) own knowledge, except as to matters therein stated to be alleged on information and belief, and as to those matters (he)(she)(they) believe(s) it to be true. Petitioner(s) Subscribed and sworn to before me this day of , . (Deputy) Clerk of the Court Notary Public American LegalNet, Inc. www.FormsWorkflow.com