Notice Of Proposed Adoption {4}

D.R. L. 111(3), 111-a(6),115(9). Adoption Form 4 (Notice of Proposed Adoption) 10/2004FAM ILY COURT OF THE STAT E OF NEW Y ORK COUNT Y OF _________________________________ In the Matter of the Adoption of G Docket G File No.A Child whose First Name is NOTICE OF PROPOSED ADOPT ION _________________________________ To: PL EA SE TA K E NOTICE that a petition requesting an order approving and allowingthe adoption of an adoptive child whose first name is [specif y]: , who isalleged to be your [specify relationship]: , and whose full name anddate and place of birth is set forth in a Schedule annexed to the petition for adoption herein,together with an agreement to adopt and consents to the adoption pursuant to the DomesticR elations Law, has been filed with the [specify] : Court of the State of NewY ork, County. A hearing on the petition will be held at the Court, located at[specify address]: on [specify date]: , at [specify time]: oclock in the G morning G afternoon ofthat day, at which time and place all persons having any interest therein will be heard. [C heck box if applicable pursuant to Domestic Relations Law 111-a(6)]: Q PLEA SE TA K E FUR THER NOTICE that your failure to appear may constitute adenial of your interest in the child, which may result, without further notice to you, in theadoption or other disposition of the custody of the child. Signature of Petitioners Attorney __________________________ Attorneys Name (print or type) ___________________________ ___________________________ Attorneys Address and Telephone Number