22 CRR-NY D IV B Form 10-BNY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 22. JUDICIARY
SUBTITLE D. FORMS
CHAPTER IV. FORMS OF THE FAMILY COURT OF THE STATE OF NEW YORK AND ADOPTION FORMS OF THE FAMILY COURT OF THE STATE OF NEW YORK (CF. § 205.7)
SUBCHAPTER B. ADOPTION FORMS OF THE FAMILY COURT
ADOPTION FORMS
22 CRR-NY D IV B Form 10-B
22 CRR-NY D IV B Form 10-B
10-B Supplemental affidavit (private-placement)
22 NYCRR 205.53(c)
 
Form 10-B
 
(Supplemental Affidavit-
 
Private-Placement)
 
9/99
FAMILY 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
 
 
SUPPLEMENTAL
 
AFFIDAVIT
 
(Private-Placement)
________________
STATE OF NEW YORK
 
)
 
 
ss:
 
COUNTY OF
 
 
)
 
(and
 
) being duly sworn, depose(s) and say(s):
1. Deponent(s) (is) (are) the same person(s) who on
 
filed in this Court a petition for adoption of the above-named adoptive child.
2. Deponent(s) (is)(are) over the age of twenty-one years, citizen(s) of the United States, and (unmarried)(married and living together) (married and living apart).
3. The post-office addresses, place(s) of residence and home telephone number(s) of petitioner(s) (is)(are)
 
Petitioner (specify name):
Petitioner (specify name):
4. Petitioner(s) hereby state(s) that there has been no change of circumstances whatsoever since the filing of said original petition, dated
 
, except as follows:
Form 10-B Page 2
Date:
 
/
 
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
Sworn to before me this
 
day of
 
, .
Judge of the Court
22 CRR-NY D IV B Form 10-B
Current through May 31, 2021
End of Document

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