N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 2-Ga - Extrajudicial consent (birth or legal parent - private-placement - step-parent)

D.R.L. §§ 115, 115-b(8) Form 2-Ga

(Extrajudicial Consent

Birth or Legal Parent -

Private-Placement

Step-parent)

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

EXTRAJUDICIAL CONSENT

(Birth or Legal Parent -

Private-Placement-

Step-parent)

________

1. I,, residing at

, am the (birth) (legal) parent of . I do hereby consent to the adoption of my (daughter)(son)

, born on

by[specify name]:, adoptive parent.

2. the name and last known address of the other (birth)(legal) parent of the adoptive child are:[FN1]

Dated: ________

/

_________________________

(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)

/

_________________________

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-ga page 2

STATE OF NEW YORK)

: ss.:

COUNTY OF)

On this day of 19,, the person who executed the foregoing instrument, personally came before me and acknowledged that (he) (she) executed the same.

______________

Notary Public

[FN1] Delete if inapplicable

Notes

N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 2-Ga