22 NYCRR 205.53(c) Form 10-A (Supplemental Affidavit Agency) 9/99 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. SUPPLEMENTAL AFFIDAVIT (AGENCY) STATE OF NEW YORK COUNTY ) ss: ) (and being duly sworn, depose(s) and say(s): That deponent(s) (is) (are) the same person(s) who on filed in this Court a petition for adoption of the above-named adoptive child. Deponent(s) reallege(s) and reaffirm(s) each of the matters set forth in said petition heretofore filed and represent(s) to the Judge of this Court that there has been no change of circumstances whatsoever since the filing of said original petition, dated: , except as follows: ) Date: _____________________________________/________________________________ Adoptive Parent: typed or printed name/ signature ______________________________________/_______________________________ Adoptive Parent: typed or printed name / signature _______________________________________________/______________________ Adoptive child if over 18: typed or printed name/ signature ______________________________________/_______________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney's Address and Telephone number Sworn to before me this day of , . 2001 � American LegalNet, Inc. ______________________________ Judge of the Court 2001 � American LegalNet, Inc.