N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 4
D.R.L. §§ 111(3), 111-a(6), 115(9). Form 4
(Notice of Proposed Adoption)
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
NOTICE OF PROPOSED
ADOPTION
________
To:
PLEASE TAKE NOTICE that a petition praying for an order approving and allowing the adoption of an adoptive child whose first name is, who alleged to be your (state relationship), and whose full name, date and place of birth is set forth in a Schedule annexed to the petition for adoption herein, together with an agreement to adopt and consents to the adoption pursuant to the Domestic Relations Law, has been filed with the Court of the State of New York,
County, and a hearing thereon will be held at the Court on the day of, 19, at o'clock in the noon of that day, at which time and place all persons having any interest therein will be heard.
PLEASE TAKE FURTHER NOTICE that your failure to appear may constitute a denial of your interest in the child which may result, without further notice to you, in the adoption or other disposition of the custody of the child.[FN1]
/
_________________________
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
[FN1] Include only where applicable pursuant to D.R.L. § 111-a(6)
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 4