N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 10-B
22 NYCRR 207.55(c) Form 10-B
(Supplemental Affidavit-
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
SUPPLEMENTAL
AFFIDAVIT
(Private-Placement)
________
STATE OF NEW YORK)
ss:
COUNTY OF)
(and)
being duly sworn, depose(s) and say(s):
1. Deponent(s) (is) (are) the same person(s) who on
filed in this Court a petition for adoption of the above-named adoptive child.
2. Deponent(s) (is)(are) over the age of twenty-one years, citizen(s) of the United States, and (unmarried)(married and living together) (married and living apart).
3. The post-office addresses, place(s) of residence and home telephone number(s) of petitioner(s) (is)(are)
Petitioner (specify name):
Petitioner (specify name):
4. Petitioner(s) hereby state(s) that there has been no change of circumstances whatsoever since the filing of said original petition, dated, except as follows:
Form 10-B page 2
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-B