N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 9-B
S.S.L. § 374(6); Form 9-B
22 NYCRR 207.55(b)(8) (Affidavit of Financial
Disclosure - Parents -
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 OF
FINANCIAL
DISCLOSURE -
PARENTS
(Private Placement)
________
STATE OF NEW YORK)
ss:
COUNTY)
(and)
being duly sworn, depose(s) and say(s):
1. That deponent(s) reside(s) at
and (is)(are)
the (petitioning adoptive parent(s) (birth or legal parent(s)) of the above-named adoptive child; and
2. That deponent(s) (has)(have) paid or given or caused to be paid or given or undertaken to pay or give the following expenses, contributions, compensation or things of value, either directly or indirectly, to any person, agency, association, corporation, institution, society or organization, in connection with the placing out of said adoptive child with deponent(s) or with the adoption of said child by deponent(s):
[Specify recipient, amount, form, and purpose of each payment. If none, so state.]
;
3. That deponent(s) (has)(have) requested, received or accepted either directly or indirectly, the following compensation or things of value from any person, agency, association, corporation, institution, society or other organization in connection with the placing out of said adoptive child with deponent(s) or with the adoption of said child by deponent(s).
Form 9-B page 2
[Specify source, amount, form
and purpose of each payment
requested or received. If none,
so state.]
/
[FN ]
_________________________
*(Adoptive)(Birth)(Legal) Parent: typed or printed name/signature
/
_________________________
*(Adoptive)(Birth)(Legal) 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
[FN ] Delete inapplicable provisions.
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 9-B