N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 10-A
22 NYCRR 207.55(c) Form 10-A
(Supplemental Affidavit
Agency)
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
SUPPLEMENTAL
AFFIDAVIT
(AGENCY)
________
STATE OF NEW YORK)
ss:
COUNTY OF)
(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, 19.
______________
Judge of the Court
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 10-A