Private Placement Adoption Proceeding Checklist

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Private Placement Adoption Proceeding ChecklistCalendar No.(see Surrogate's Court Form 1-C, rev. 12/97)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)NOTE: If adoptive child has resided with adoptive step-parent and birth parent less than one year, a petition for certification (Form 22) must be filed. [See D.R.L. §115-d(8)]Fill In All Areas On All Pages -Also Mark When Not Applicable When NecessaryCheck All Forms To Make Sure Venue Is Correct -Appropriate County Is Listed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NOTE: Check SCPA §1725 to see if youneed to do a Temporary Guardianship (Form 21-A) by adoptive parents, prior to the adoption.THE PEOPLE OF THE STATE OF NEW YORK TOPET¶ #DESCRIPTIONNOYESGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,BE SURE THE SURNAME OF THE CHILD IS NOT LISTED IN ANY DOCUMENT HEADING. 1located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomIs the name of the first petitioning adoptive parent filled in? See Domestic Relations Law. 1(a)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Is the residency of the adoptive parent, including county listed? NOTE: The proposed adoptive parent(s) must reside in the county, or if the proposed adoptive parent(s) do not reside in New York State, the child must reside in the county. 1(b), one of the Justices of theCourt in Witness, Honorableday of, 20 County,Is the age and date of birth listed? NOTE: At least one of the petitioners must be over eighteen (18) years of age. 1(c)Is the marital status and living arrangements filled in? 1(d)(Attorney must sign above and type name below)Is the adoptive parent's religious faith filled in? See Social Services Law §373.3. 1(e)Attorney(s) forIs the occupation and earnings of the adoptive parent filled in? NOTE: If any monies are received from the Commissioner of Social Services on behalf of the adoptive child that amount must be included. 2Follow above instructions in #1 for second adoptive parent. 2(a)Office and P.O. AddressFollow above instructions in #1(a). 2(b)Follow above instructions in #1(b). 2(c)Telephone No.: Facsimile No.: E-Mail Address:Follow above instructions in #1(c). 2(d)Follow above instructions in #1(d).Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comPRIV-ADPTN-CHK release 7/14/03 PAGE 1COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.PETCalendar No.¶ #DESCRIPTIONYESNOJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)2(e)Follow above instructions in #1(e). 3Is the full name, date and place of birth of the adoptive child noted? NOTE: A certified copy of the child's birth certificate from the official registrar must be attached to the petition. 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Is the child's religious faith, if any, noted? See Social Services Law §373.3 5(a)Is the name and address of the birth or legal parents of the adoptive child listed? 5(b)THE PEOPLE OF THE STATE OF NEW YORK TOIs the age and date of birth of the birth or legal parents of the adoptive child listed? 5(c)Is the heritage (specific nationality, ethnic background, race) of the adoptive child listed? 5(d)GREETINGS:Is the religious faith, if any, of the birth or legal parents of the adoptive child listed? See Social Services Law §373.3. 5(e)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofIs the education (specific number of years of school, or degrees completed at time of birth of adoptive child) of the birth or legal parents of the adoptive child listed? 5(f)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomIs the height, weight, hair color, eye color, skin of the birth or legal parents listed? 5(g)Is Form 1-D, which provides health and medical history at time of birth of adoptive child, including conditions or diseases believed to be hereditary and any drugs or medications taken during pregnancy by the child's mother annexed to the petition? NOTE: Some courts may require additional separate forms as to medical history of the birth mother and birth father.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.5(h), one of the Justices of theCourt in Witness, Honorableday of, 20 County,Are the talents, hobbies and special interests of the birth or legal parents of the adoptive child listed? 6(Attorney must sign above and type name below)Is the manner in which the adoptive parent(s) obtained the adoptive child noted? See Domestic Relations Law §115(1)(a). 7Attorney(s) forHas the time span the adoptive child has resided with the adoptive parents been indicated? 8Has the names and dates of birth of other persons living in the household been indicated? 9Office and P.O. AddressIf the adoptive child's name is to be changed, is the proposed name listed and spelled correctly? 10Telephone No.: Facsimile No.: E-Mail Address:Is it stated whether the adoptive child has or has not been previously adopted? 11Are the name(s) and address(es) of any person(s) having lawful custody of the adoptive child, if known, listed?Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comPRIV-ADPTN-CHK release 7/14/03 PAGE 2COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.PETCalendar No.¶ #DESCRIPTIONYESNOJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Does the petition set forth that all necessary consents are attached or have suffici