N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 1-Ca
D.R.L. §§ 115, 115-d Form 1-Ca
(Affidavit - Change of
Circumstance)
Private-Placement
12/97
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________
In the Matter of the Adoption of (Docket)(File) No.
A Child Whose First Name is
AFFIDAVIT
(Change of
circumstance since
certification as qualified
adoptive parent)
(Private-Placement)
________
STATE OF NEW YORK)
:ss.:
COUNTY OF)
, being duly sworn depose(s) and say(s):
1. Deponent(s) (was)(were) certified as (a) qualified adoptive parent(s) by order of the Court, County of, dated, 19 ;
2. The following change(s) in circumstance relevant and material to such certification (has)(have) taken place since that date:
Date:
______________
Petitioner
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone Number
Sworn to before me this day of, 19.
________
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 1-Ca