Judicial Consent (Birth or Legal Parent Private Placement)

This form is to be used in drafting a Judicial Consent of the birth or legal Parent in a Private Placement.Download

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D.R.L. §§115, 115-b Form 2-F
Judicial Consent -
Birth or Legal Parent -
Private-Placement)
8/2002
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
    JUDICIAL CONSENT
(Birth or Legal Parent
-- Private-Placement)
 ____________________________
THIS CONSENT BECOMES IRREVOCABLE UPON EXECUTION OR
ACKNOWLEDGMENT BEFORE ANY JUDGE OR SURROGATE IN
NEW YORK STATE OR A COURT OF COMPETENT JURISDICTION IN
ANOTHER STATE HAVING JURISDICTION OVER ADOPTION
PROCEEDING(S).  NO ACTION OR PROCEEDING FOR THE CUSTODY
OF THE ADOPTIVE CHILD MAY BE MAINTAINED BY THE PARENT
EXECUTING OR ACKNOWLEDGING THE WITHIN CONSENT. 
                                  ; optional]:
1. I, [specify name]:                              , residing at                                          ,
(birth)(legal) parent of  [specify first name]: 
                               , do hereby consent to the adoption of my (daughter)(son) who was born on
[specify date]:                     (by [specify name(s); optional]:                                                                  ,
adoptive parent(s)).
2.  I have been advised that this consent becomes irrevocable when executed or acknowledged
before a judge or surrogate, and thereafter no action or proceeding may be maintained by me for the
custody of the child.  I also have been advised that before I acknowledge or execute this consent, I
have a right to be represented by a lawyer of my own choosing and, if I am financially unable to obtain
same, a lawyer will be assigned at public cost.  I further have been advised that I have a right to obtain
supportive counseling.
*3.  The full name and last known address of the other (birth)(legal) parent of the adoptive
child are:
Dated: Signature:

Form 2-f Page 2	
______________________________________/______________________________
(Birth)(Legal) parent: typed or printed name/ signature
______________________________________/________________________________
Attorney if any: typed or printed name/signature
______________________________________________________________________
Attorney’s Address and Telephone number	
State of )
ss.:
County of )
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 judicial surrender. 
(He)(She) acknowledged to me that (he)(she) executed this surrender. I have informed (him)(her) of
the consequences of the act of execution and acknowledgment pursuant to the provisions of section
115-b of the Domestic Relations Law and have informed (him)(her) of the right to be represented by
legal counsel of (his)(her) own choosing; of the right to obtain supportive counseling and of any rights
to assigned counsel pursuant to section 262 of the Family Court Act, section 407 of the Surrogate's
Court Procedure Act, or section 35 of the Judiciary Law.  I have given (him)(her) a copy of this
consent upon execution thereof.
________________________________
Judge of the  Court
(Seal of Court to be
 affixed together
 with Court Clerk's 
 certification)