N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 26-a - Affidavit and report (disinterested person-extension of expired certification)

D.R.L. §§ 115, 115-d(9) Form 26-a

(Certification as

Qualified Adoptive

Parent)

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 and

REPORT

(Disinterested Person-

Extension of Expired

by Certification)

Adoptive Parent(s)

________

[Name], being duly sworn, deposes and

says that:

1. I am a disinterested person as defined in section 115-d (4) of the Domestic Relations Law in that (he)(she) has no interest in the outcome of the application of the part(y)(ies) herein for certification as (a) qualified adoptive parent(s).

2. The following fee(s) (have been) (will be) paid to deponent for services rendered in connection with the application for extension of certification:

3. I have read the affidavit and report prepared by

and submitted in support of the petition for certification as (a) qualified adoptive parent(s) submitted by petitioner(s) on, 19 . On information and belief, an order granting certification as a qualified adoptive parent(s) was made by the Court,

County, on, 19, and expired on, 19.

4. The following Change(s) in circumstances relevant and material to the extension of such certification (has)(have) taken place since the issuance and expiration of the last certification:

5. The source of my knowledge concerning the circumstances of the petitioner's(s') family and household is: [include date, place and duration of personal interview and visit at petitioner's(s') home.]

Form 26-a page 2

Dated:

______________

Petitioner

______________

Print or type name

______________

Signature of Attorney, if any

______________

Attorney's Name (Print or Type)

________

________

______________

Attorney's Address and Telephone Number

Sworn to before me this day of, 19.

______________

Notary Public

Notes

N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VII, subch. B, Adoption Forms, form 26-a