Judiciary of New York
D.R.L. §114 Adoption Form 27-D
(Adoption–Waiver of Notice of
Petition for Access to
Sealed Adoption Records)
(9/2006)
SURROGATE’S 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 ______________________
WAIVER OF NOTICE OF PETITION FOR ACCESS TO SEALED
_____________________________________________ ADOPTION RECORDS
...........................................................................................
1. I am the [check applicable box]: □ Adoptive Mother □ Adoptive Father □ Other [specify]: _______________________of the above-named child. I am 18 years of age or older.
2. I am waiving the service of Notice of Petition for Access to Sealed Adoption Records in this matter and am consenting to the release of sealed adoption records to [specify]:__________
________________________________________________________________________________
Dated:____________,_____. ________________________________
(Signature of Interested Party)
_________________________________
(Print Name)
STATE OF____________________)
COUNTY OF_________________) SS:
On the___________________ day of ______________in the year_________, before me, the undersigned, __________________________________________________________________________
personally appeared_________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual (s) whose name (s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signatures (s) on the instrument, the individual (s), or the person, upon behalf of which the individual (s) acted, executed the instrument.
_______________________________________
Notary Public
(Deputy ) Clerk of Court
_____________________________________
Signature of Attorney, if any
_____________________________________
Attorney’s Name (print or type)
_____________________________________
_____________________________________
Attorney’s Address and Telephone Number
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