Private Placement Adoption Proceeding Checklist (see Surrogate’s Court Form 1-C, rev. 9/06) [references DRL §§111, 111-a, 112, 115, and SCPA §1725(1)] This Checklist is provided for your convenience while completing the petition and the checklist should not be returned to the Court. NOTE: If adoptive child has resided with adoptive step-parent and birth parent less than one year, a petition for certification (Form 22) must be filed. [See D.R.L. §115-d(8)] Fill In All Areas On All Pages - Also Mark When Not Applicable When Necessary Check All Forms To Make Sure Venue Is Correct - Appropriate County Is Listed NOTE: Check SCPA §1725 to see if you need to do a Temporary Guardianship (Form 21-A) by adoptive parents, prior to the adoption. PET ¶# DESCRIPTION YES NO BE SURE THE SURNAME OF THE CHILD IS NOT LISTED IN ANY DOCUMENT HEADING. 1 1(a) Is the name of the first petitioning adoptive parent filled in? See Domestic Relations Law. Is the residency of the adoptive parent, including county listed? NOTE: The proposed adoptive parent(s) must reside in the county, or if the proposed adoptive parent(s) do not reside in New York State, the child must reside in the county. 1(b) Is the age and date of birth listed? NOTE: At least one of the petitioners must be over eighteen (18) years of age. 1(c) Is the marital status and living arrangements filled in? 1(d) Is the adoptive parent’s religious faith filled in? See Social Services Law §373.3. 1(e) Is the occupation and earnings of the adoptive parent filled in? NOTE: If any monies are received from the Commissioner of Social Services on behalf of the adoptive child that amount must be included. 2 Follow above instructions in #1 for second adoptive parent. 2(a) Follow above instructions in #1(a). 2(b) Follow above instructions in #1(b). 2(c) Follow above instructions in #1(c). 2(d) Follow above instructions in #1(d). 2(e) Follow above instructions in #1(e). PRIV-ADPTN-CHK release 2/22/07 PAGE 1 American LegalNet, Inc. www.FormsWorkflow.com PET ¶# 3 DESCRIPTION YES NO Is the full name, date and place of birth of the adoptive child noted? NOTE: A certified copy of the child’s birth certificate from the official registrar must be attached to the petition. 4 Is the child’s religious faith, if any, noted? See Social Services Law §373.3 5(a) Is the name and address of the birth or legal parents of the adoptive child listed? 5(b) Is the age and date of birth of the birth or legal parents of the adoptive child listed? 5(c) Is the heritage (specific nationality, ethnic background, race) of the adoptive child listed? 5(d) Is the religious faith, if any, of the birth or legal parents of the adoptive child listed? See Social Services Law §373.3. 5(e) Is the education (specific number of years of school, or degrees completed at time of birth of adoptive child) of the birth or legal parents of the adoptive child listed? 5(f) Is the height, weight, hair color, eye color, skin of the birth or legal parents listed? 5(g) Is Form 1-D, which provides health and medical history at time of birth of adoptive child, including conditions or diseases believed to be hereditary and any drugs or medications taken during pregnancy by the child’s mother annexed to the petition? NOTE: Some courts may require additional separate forms as to medical history of the birth mother and birth father. 5(h) Are the talents, hobbies and special interests of the birth or legal parents of the adoptive child listed? 6 Is the manner in which the adoptive parent(s) obtained the adoptive child noted? See Domestic Relations Law §115(1)(a). 7 Has the time span the adoptive child has resided with the adoptive parents been indicated? 8 Has the names and dates of birth of other persons living in the household been indicated? 9 If the adoptive child’s name is to be changed, is the proposed name listed and spelled correctly? 10 Is it stated whether the adoptive child has or has not been previously adopted? PRIV-ADPTN-CHK release 2/22/07 PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com PET ¶# DESCRIPTION 11 NO Are the name(s) and address(es) of any person(s) having lawful custody of the adoptive child, if known, listed? 12 (a-d) YES Does the petition set forth that all necessary consents are attached or have sufficient facts been detailed for the Court to dispense with the consent(s). See Domestic Relations Law §109(6), §111, §111-a, §115, §115-b. Use appropriate consent form(s): 2D, 2F, 2Fa, 2G or 2Ga. NOTE: Some courts may dispense with consent(s) only after a citation has been issued and properly served. NOTE: If the adoptee is over eighteen (18) years of age, the consent of the natural parent(s) is not required. 13 (a-b) Has the name(s) of the consenting birth or legal parent(s) been listed with the date of the consent(s); if extra-judicial, has the correct 45th date been noted? See D.R.L. §115-b(3). 14 This paragraph states that on information and belief that the named court in an extra-judicial consent has not received any written notice of revocation and that more than 45 days have elapsed. 15 If there has been a guardian (general or testamentary) named for the adoptive child, has the nature, date and place of appointment been listed? 16 Have the names of any further interested persons entitled to notice been listed along with their relationship? See D.R.L. §111(3) and §111-a. 17 Check appropriate boxes and submit form 1-E if required. 18 Make sure that Form 1-D has been attached with child’s medical information along with any other medical forms required by court. 19 If child was brought from another state has proper documentation been attached from the Interstate Compact? See S.S.L. §374-a and §382. 20(a) Is it indicated whether there is any knowledge of child abuse or maltreatment involving the child or the adoptive parent? See S.S.L. §412. NOTE: Form DSS-4156 must be submitted. 20(b) Is it indicated whether any adult residing in the adoptive parent(s) household has a criminal record? NOTE: Fingerprint cards (Form DCJS-6 rev. 1/89) must be submitted. 21 Is it indicated whether there are any prior or pending proceedings affecting this adoptive child? If so, has sufficient information been provided? 22 Is it indicated whether the adoptive child is an Indian (Native American) child? See 25 U.S.C. §§1901-1963. PRIV-ADPTN-CHK release 2/22/07 PAGE 3 American LegalNet, Inc. www.FormsWorkflow.com PET ¶# 23 DESCRIPTION YES NO Have any additional allegations been indicated? Check that the “Wherefore” clause lists all relief requested including the correct listing and spelling of a change in the adoptive child’s name. Is petition dated, signed, verified, properly notarized (including proper jurat and expiration date of notary’s commission)? Is attorney’s name, address and phone number listed? Has Part 130 Certification been completed? if NOT, has a separate attorney certification as to Part 130 signing requirements been included? If forms are computer generated, has a certification pursuant to Court Rules §207.4 been attached? ADDITIONAL ADOPTION DOCUMENT REQUIREMENTS Certified Birth Certificate of Adoptive Child (from official registrar) Certified copy of marriage record of the adoptive parents. Confidential Affidavit with certified copies of divorce decrees. Photocopies of adoptive parent’s birth certificates. Doctor’s certificate of health for adoptive parents and adoptee (examinations must be done within six months of filing petition). Report of Adoption (Form VS-43 10/71). [If adoptee was born in another state the report of adoption form should be obtained from that state’s vital statistics bureau.] 1-C Petition for Adoption 1-Ca Affidavit of Change in Circumstances (required if there has been a change in circumstances since certification). 1-D Child’s Medical History (with additional birth parent health information required by Court). 1-E Affirmation Regarding Venue 1-F Determination of Family Court Judge Regarding Venue 1-G Order Regarding Venue 2-B Agreement of Adoption. 2-D Consent of Child Over 14 PRIV-ADPTN-CHK release 2/22/07 PAGE 4 American LegalNet, Inc. www.FormsWorkflow.com 2-E Affidavit & Consent of Person having Lawful Custody of adoptee other than birth or legal parent. Affidavit of Paternity (if applicable). 2-F Judicial Consent (consent taken before judge of birth or legal parent relinquishing parental rights) Additional Adoption Documentation Requirements (continued) 2-Fa Judicial Consent (consent taken before judge of birth or legal parent consenting to step-parent adopting child) 2-G Extrajudicial Consent (consent taken before notary of birth or legal parent relinquishing parental rights) 2-Ga Extrajudicial Consent (consent taken before notary of birth or legal parent consenting to step-parent adopting child) 6-B Order for Investigation 7 Report of Investigation by Probation Department or Social Services 8-B Affidavit of Identifying Party (where affiant is not the attorney of record) 8-C Affidavit of Identifying Party (where affiant is the attorney of record) Affirmation (by attorney of record) [with attached retainer agreement] 9-B Affidavit of Financial Disclosure - Parents Attorney’s Affidavit (Form UCS-836) [an index number from the Court is required before mailing original affidavit to Office of Court Administration with a copy to Court - OCA requires that a 3"x5" postcard be supplied with affidavit for return notice of state tracking number, the postcard must be filed with Court.] 10-B Supplemental Affidavit Narrative Affidavit by adoptive parent(s) (if required by court) 13-B Order of Adoption (proposed) 15-A Application for Certified Copy of Adoption Order (before sealing of records) 15-B Order for Certified Copy of Adoption Order (before sealing of records) CERTIFICATION DOCUMENTATION REQUIREMENTS 22 Petition (Certification as a Qualified Adoptive Parent) Certified Birth Certificate (from official registrar) Consents to Adoption (if applicable) Certified copy of Marriage Certificate Affidavit of Prior Marriages (if required by court) PRIV-ADPTN-CHK release 2/22/07 PAGE 5 American LegalNet, Inc. www.FormsWorkflow.com Certified copies of divorce decrees. DSS-4156 Request for Information Fingerprint Cards 23 Affidavit and Report (of Disinterested Person) TEMPORARY GUARDIANSHIP DOCUMENTATION REQUIREMENTS 21-A Petition for Temporary Guardianship 2-F Judicial Consent (Natural Parent) [copy to be attached to petition] 21-E Affidavit (Change of circumstances since certification as qualified adoptive parent) THIS MATERIAL IS PROVIDED FOR INFORMATIONAL/TRAINING PURPOSES ONLY. – It is intended for use in conjunction with review of the applicable statutes and rules of the Surrogate’s Court and the Surrogate’s Court Operations Manual. PRIV-ADPTN-CHK release 2/22/07 PAGE 6 American LegalNet, Inc. www.FormsWorkflow.com