N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 2-C
Sec. 111(1)(a) D.R.L. Adoption Form 2-C
(Consent of Child-
Agency)
12/97
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
CONSENT OF CHILD
OVER 14
________
The undersigned adoptive child, who is years old, having been born on, hereby consents to (his) (her) adoption by
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
Dated:
______________
Child
/
_________________________
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
Form 2-C page 2
STATE OF NEW YORK)
: ss.:
COUNTY OF)
On this day of, 19, before me personally came
, to me known and known to be the person described in and who executed the foregoing instrument and
duly acknowledged to me that executed the same.
______________
Notary Public
STATE OF NEW YORK)
: ss.:
COUNTY OF)
On this day of, 19, before me personally came
proven to me by the oath of
an attorney admitted to practice in the State of New York to be the person described in and who executed the foregoing instrument and
duly acknowledged that executed the same.
________
Judge of the Court
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 2-C