22 CRR-NY D IV B Form 21-ANY-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 21-A
22 CRR-NY D IV B Form 21-A
21-A Petition for temporary guardianship
D.R.L. § 115-c; S.C.P.A. § 1725
Form 21-A
(Temporary
Guardianship)
12/97
FAMILY COURT OF THE STATE OF NEW YORK
COUNTY OF
________________
In the Matter of the Temporary
Guardianship of a Child Whose
(Docket) (File) No.
First Name is
Petition for Temporary
Guardianship
________________
The Petitioner(s) respectfully allege(s) to the Court that:
1. Physical custody of (first name)
(last name)
, a child born on
, was transferred to
and
, for the purposes of adoption on the
day of
, 19 , by
, the child's (parent(s))(guardian(s)), (and requirements for certification of
as, qualified adoptive parents herein was duly waived by order of the
Court, County of
dated
2. The residence and telephone number of Petitioner(s) is
3. The full name(s) and address(es) of the natural parent(s) of the child are:
.
4. The anticipated name of the child subsequent to adoption will be
.
5. The anticipated residence of the child subsequent to adoption will be
.
Form 21-A page 2
6. A consent to the adoption of the child was duly executed pursuant to section 115-b of the Domestic Relations Law on
, 19 . A copy of the consent to the adoption is annexed hereto.
7. The child will be residing with Petitioner(s), and a petition for adoption of the child by Petitioner(s) will be filed in the
Court of the County of
, State of New York, within 45 days of the execution of the consent to adoption of the child.
8. No previous petition has been filed or application made to any court or judge for the relief sought herein (except) [include any proceedings dismissed or withdrawn]
WHEREFORE, Petitioner(s) pray(s) for an order granting temporary guardianship of the child to Petitioner(s).
Petitioner(s)
______________
Applicant
Print or type name
Signature of Attorney, if any
Attorney's Name (Print or Type)
______________
______________
Attorney's Address and Telephone Number
Dated:
19
Form 21-A page 3
VERIFICATION
STATE OF NEW YORK
)
) ss.:
COUNTY OF
)
, being duly sworn, says that (he) (she) (they) (is)(are) the Petitioner(s) in the above-named proceeding and that the foregoing petition is true to (his) (her) (their) own knowledge, except as to matters therein stated to be alleged on information and belief, and as to those matters (he)(she)(they) believe(s) it to be true.
Petitioner(s)
Subscribed and sworn to before me this
day of
, 19 .
(Deputy) Clerk of the Court Notary Public
22 CRR-NY D IV B Form 21-A
Current through May 31, 2021
| End of Document |
IMPORTANT NOTE REGARDING CONTENT CURRENCY: The "Current through" date indicated immediately above is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Administrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of NYS Rules.