Extra Judicial Consent (Birth Or Legal Parent Private Placement Step Parent) {2-Ga}

D.R.L. §§ 115, 115-b(8) Form 2-Ga (Extrajudicial Consent Birth or Legal Parent Private-Placement Step-parent) 8/2002 COURT OF THE STATE OF NEW YORK COUNTY OF _____________________________ In the Matter of the Adoption of A Child whose First Name is (Docket)(File) No. EXTRAJUDICIAL CONSENT (Birth or Legal Parent Private-Placement Step-parent) ______________________________ , residing at , am the (birth) (legal) parent of to the adoption of my (daughter) (son) , born on by [specify name]: , adoptive parent. 1. I, . I do hereby consent 2. The name and last known address of the other (birth)(legal) parent of the adoptive child are [delete if inapplicable]: Dated: ______________________________/_____________________________________ (Birth)(Legal) Parent: typed or printed name/ signature _____________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney's Address and Telephone number STATE OF NEW YORK COUNTY OF ) :ss: ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this extrajudicial surrender. (He)(She) acknowledged to me that (he)(she) executed this surrender. ____________________________ Notary Public American LegalNet, Inc. www.USCourtForms.com