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OCFS-4315 (Rev. 02/2016)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

JUDICIAL SURRENDER

|Sec. 383-c, SSL Judicial Surrender |

|COURT OF THE STATE OF NEW YORK |

|COUNTY OF       |

|In the Matter of the Surrender for JUDICIAL SURRENDER |

|Adoption of a Child Whose Name Is       Docket No:       |

| |

I UNDERSTAND THAT IMMEDIATELY UPON MY SIGNING AND ACKNOWLEDGING THIS SURRENDER BEFORE THE COURT, THE SURRENDER BECOMES FINAL AND CANNOT BE CANCELLED OR CHANGED AND I CANNOT BRING A CASE IN COURT TO CANCEL OR CHANGE THE SURRENDER OR TO REGAIN CUSTODY OF MY CHILD.

I understand that I have the right to speak to a lawyer of my own choosing and to any other person I wish before I sign this surrender. I have the right to have that lawyer and any other person present with me at the time I sign this surrender. In addition, I have the right to ask the court to appoint a lawyer free of charge if I cannot afford to hire one. I also understand that I have the right to have supportive counseling about surrendering my child before I sign this document.

I understand that I cannot be forced to sign this surrender paper. My child and I cannot be punished or penalized if I refuse to sign this surrender.

I understand that my child will be adopted without my further consent and without further notice, and will be adopted by any person the authorized agency chooses, unless this surrender contains the name of the person or persons who will be adopting the child.

I understand that I am giving up all rights to have custody of, visit with, speak with, write to or learn about my child forever, unless I, the authorized agency, designated adoptive parent(s), if applicable, and the attorney for the child agree to different terms, as stated in Attachment A of this surrender or, unless both the child and I register with the Adoption Information Registry in accordance with Public Health Law section 4138-d. If both the child and I register with the Adoption Information Registry, regardless whether I choose Choice 1 or Choice 2 below, the child may contact me at any time after he or she reaches the age of 18.

I understand that I must check Choice 1 or 2 below for this surrender.

If I choose:

CHOICE 1: I am surrendering my child without conditions.

CHOICE 2: I am surrendering my child upon the terms and conditions listed in Attachment A of this surrender.

These conditions may include my wish that my child be adopted by a person or persons that have been identified as the adoptive parent(s) and agreed to by the authorized agency in Attachment A.

___________________________________________________________________________________

CHOICE 1

I choose to surrender my child without any conditions. Upon signing and acknowledging before the judge this surrender of guardianship and custody of my child, I am giving up all rights to have custody of, visit with, speak with, write to or learn about my child, forever.

|My child will be adopted without my further consent and without further notice to me. My child will be |

|adopted by any person that the       (Name of Authorized Agency) authorized agency chooses. |

___________________________________________OR______________________________________

CHOICE 2

I choose to surrender my child with conditions.

|I have agreed to with the authorized agency      , (Name of Authorized Agency) |

attorney for the child, and the person(s) who will adopt my child, if the adoptive parent(s) is identified in Attachment A. The condition(s) and information about my rights and obligations, including notice requirements, and those of the authorized agency and adoptive parent(s), are contained in Attachment A to this surrender.

___________________________________________________________________________________

PLEASE FILL IN AND SIGN THE FOLLOWING:

|I,       (Name) residing at       (Address) as the ( mother) ( father) ( legal guardian) of       (Child's Name) do hereby voluntarily surrender |

|guardianship and custody of my ( daughter) ( son) ( ward), born on       to       (a duly Authorized Agency) |

|      | |Dated: |      |

|(PARENT OR LEGAL GUARDIAN) | | |

|State of       |

|County of       )ss.: |

|On this       day of       20   before me personally came       |

the person(s) described in and who executed the foregoing instrument, and (he) (she) acknowledged that (he) (she) executed the same. I have informed such person(s) of the consequences of the act of execution and acknowledgment pursuant to the provisions of Section 383-c of the Social Services Law including that (he) (she) is giving up all rights to have custody, visit with, speak with, write or learn about the child, forever, unless (he) (she) and the authorized agency, designated adoptive parent, if applicable and attorney for the child agree to different terms as specified in this surrender in Attachment A to this surrender or if (he) (she) and the adult child register with the Adoption Information Register. I have informed (him) (her) that the surrender becomes final and irrevocable immediately upon its execution and acknowledgement. I 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 surrender upon execution thereof.

___________________________________________________________________________________

|Judge of the       Court, County of       |

|(Seal of Court to be affixed together with Court Clerk's certification) |

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