OCFS-4156 - New York State Office of Children and Family ...
OCFS-4156 (Rev. 06/2007) FRONT
|NEW YORK STATE |SCR USE: BATCH# |
|OFFICE OF CHILDREN AND FAMILY SERVICES | |
|ORDER OF ADOPTION | |
|FAMILY COURT/SURROGATE COURT REQUEST FORM | |
|RESOURCE ID #: |COURT LIAISON |AREA CODE/PHONE # |
| | |( ) - |
|DOCKET FILE # |COURT NAME AND ADDRESS |ZIP CODE |
| | | |
|Section 112 of the Domestic Relations Law, as amended by Chapter 164 of the laws of 1991, requires that an inquiry be made of the New York Statewide Register |
|of Child Abuse and Maltreatment (SCR) to determine if the adoptive parent(s) are the subject of an indicated child abuse or maltreatment report. |
|Date of Request: | | | |
|TO BE FILLED OUT BY ADOPTIVE PARENT(S) |
|LAST NAME (father) |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|ALIAS NAME(S) | | |
| | | |
|CURRENT ADDRESS: STREET |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
|PRIOR ADDRESS(ES) (STREET) FOR THE LAST 28 YEARS |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
|LAST NAME (mother) |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|ALIAS NAME(S) | | |
| | | |
|CURRENT ADDRESS: STREET |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
|PRIOR ADDRESS(ES) (STREET) FOR THE LAST 28 YEARS |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
| |CITY |STATE |ZIP |FROM |TO |
| | | | | | |
|MEMBERS OF ADOPTIVE PARENT(S) HOUSEHOLD |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
|LAST NAME & MAIDEN/ALIAS |FIRST NAME |MI |SEX |DATE OF BIRTH |
| | | |M F | |
OCFS-4156 (Rev. 02/2009) REVERSE
COURT INSTRUCTIONS
|RESOURCE ID # |Record your Resource ID # as appropriate. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us |
|DOCKET/FILE #: |Record your Court Docket File # as appropriate. |
|COURT LIAISON: |Record name of Court Liaison. |
|DATE OF REQUEST: |Record the Court processing date. |
|Order of Adoption Family Court/Surrogate Court forms are to be sent to: |
| |The New York Statewide Central Register |
| |Of Child Abuse and Maltreatment |
| |P.O. Box 4480, Attn: Service Center Unit |
| |Albany, N.Y. 12204-0480 |
TO ORDER MORE FORMS:
Please access the Request for Forms and Publications form, (OCFS-4627) from the Internet:
Mail your completed Request for Forms and Publications, (OCFS-4627) to the Office of Children and Family Services, Forms Management Unit, Resource Distribution Center, 11, Fourth Ave, Rensselaer, NY 12144-2629. If you have difficulty accessing the form from the web-site, you can call The Forms Hot Line at: 518-473-0971.
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