Agency Adoption Proceeding Checklist

(see Surrogate's Court Form 1-A, rev. 12/97)

NOTE: DRL §112-a and 22 NYCRR 207.62 require expeditious calendaring of agency adoption hearings. The mandated time schedules begin to run "upon the filing of the adoption." The adoption is deemed filed upon receipt by the Clerk of the following: Petition (Form 1-A), Child's Medical History (Form 1-D), Agency's Verified Schedule (Form 1-B), any required agreements and consents (Form 2-A, surrender[s]), completed DSS Request for Information Form, and Certificate of Readiness.

Fill In All Areas On All Pages - Also Mark When Not Applicable When Necessary
Check All Forms To Make Sure Venue Is Correct - Appropriate County Is Listed

NOTE: to determine the Court's jurisdiction - the petition must be filed in the county where termination of parental rights or judicial surrender proceedings are pending; in any other agency adoption proceeding, the petition must be filed in the county in which parental rights have been terminated or a judicial surrender was approved or in the county where the adoptive parent(s) reside or if such parents do not reside in the state in the county where the authorized agency has its principal office. [DRL §113(3)]. 
1 Is the name of the first petitioning adoptive parent filled in? See Domestic Relations Law.    
1(a) Is the residency of the adoptive parent, including county listed?    
1(b) Is the age and date of birth listed?    
NOTE: At least one of the petitioners must be over eighteen (18) years of age.
1(c) Is the marital status and living arrangements filled in?    
1(d) Is the adoptive parent's religious faith filled in? See Social Services Law §373.3.    
1(e) Is the occupation and earnings of the adoptive parent filled in?    
NOTE: If any monies are received from the Commissioner of Social Services on behalf of the adoptive child that amount must be included.
2 Follow above instructions in #1 for second adoptive parent.    
2(a) Follow above instructions in #1(a).    
2(b) Follow above instructions in #1(b).    
2(c) Follow above instructions in #1(c).    
2(d) Follow above instructions in #1(d).    
2(e) Follow above instructions in #1(e).    
3 Is the first name, date and place of birth, and religious faith of the adoptive child noted?    
NOTE: A certified copy of the child's birth certificate from the official registrar must be attached to the petition.
4 Is the name of the agency's official listed?    
Is the verified schedule (form 1-B) included? See DRL §112(3)    
5(a) Is the age and date of birth of the birth or legal parents of the adoptive child listed?    
5(b) Is the heritage (specific nationality, ethnic background, race) of the adoptive child listed?    
5(c) Is the religious faith, if any, of the birth or legal parents of the adoptive child listed? See Social Services Law §373.3.    
5(d) Is the education (specific number of years of school, or degrees completed at time of birth of adoptive child) of the birth or legal parents of the adoptive child listed?    
5(e) Is the height, weight, hair color, eye color, skin of the birth or legal parents listed?    
5(f) Is Form 1-D, which provides health and medical history at time of birth of adoptive child, including conditions or diseases believed to be hereditary and any drugs or medications taken during pregnancy by the child's mother annexed to the petition?    
NOTE: Some courts may require additional separate forms as to medical history of the birth mother and birth father.
5(g) Are the talents, hobbies and special interests of the birth or legal parents of the adoptive child listed?    
6 Is it indicated whether the adoptive child is an Indian (Native American) child? Refer to the Indian Child Welfare Act of 1978 (25 U.S.C. §§1901-1963).    
7 Is the manner in which the adoptive parent(s) obtained the adoptive child noted?    
8 If child was brought from another state has proper documentation been attached from the Interstate Compact? See S.S.L. §374-a and §382.    
9 Has the time span the adoptive child has resided with the adoptive parents been indicated with specific dates?    
10 Has the names and dates of birth of other persons living in the household been indicated?    
11 If the adoptive child's name is to be changed, is the proposed name listed and spelled correctly?    
12 Is it stated whether the adoptive child has or has not been previously adopted?    
13 Have the names of any further interested persons entitled to notice been listed along with their relationship? See D.R.L. §111(3) and §111-a.    
14(a) Is it indicated whether there is any knowledge of child abuse or maltreatment involving the child or the adoptive parent? See S.S.L. §412.    
NOTE: Form DSS-4156 must be submitted.
14(b) Is it indicated whether any adult residing in the adoptive parent(s) household has a criminal record?    
NOTE: Fingerprint cards (Form DCJS-6 rev. 1/89) must be submitted.
15 Is it indicated whether there are any prior or pending proceedings affecting this adoptive child? If so, has sufficient information been provided?    
16 Have any additional allegations been indicated?    
Check that the "Wherefore" clause lists all relief requested including the correct listing and spelling of a change in the adoptive child's name.    
Is petition dated, signed, verified, properly notarized (including proper jurat and expiration date of notary's commission)?    
Is attorney's name, address and phone number listed?    
Has Part 130 Certification been completed?    
if NOT, has a separate attorney certification as to Part 130 signing requirements been included?    
If forms are computer generated, has a certification pursuant to Court Rules §207.4 been attached?

Within sixty (60) days of the filing of the above documents, the Court must schedule a review of the documents and determine if there is an adequate basis for approving the adoption.
If there is an adequate basis for approving the adoption, within thirty (30) days of the review, the Court shall schedule the appearance of the proposed adoptive parent(s) and the child.
If after the review, the Court finds that there is not an adequate basis for the approval of the adoption, the Court shall direct such further hearings, submissions or appearances as may be required, and the proceeding shall be adjourned as required for such purposes.



Form Number
or Rule #
Forms Required from Adoptive Parent(s) or Attorney .Petition for Adoption 
.Copy of Birth Certificate(s) of Adoptive Parent(s) if required by court 
.Certified Copy of Marriage Record 
.Certified Copy of Divorce Decree(s) 
.Agreement of Adoption and Consent (previously executed and acknowledged by agency) 
.Consent of Child Over 14 
.Affidavit of Identifying Party 
.Affidavit of Financial Disclosure 
.Attorney's Affirmation if required by court 
.Affidavit of Attorney 
.Supplemental Affidavit 
.Confidential Affidavit if required by court 
.Report of Adoption 
.Narrative Affidavit from Adoptive Parent(s) - if required by court 
.Fingerprint Card(s) 
.Proposed Order of Adoption





111-a(1), 112 


111(1)(f), 112(2)(b), 113 


111, 112(b), 113, 114

Forms Required from Adoption Agency .Certified Birth Certificate of Adoptive Child 
.Doctor's Certificate of Health for Adoptive Parent(s) and Adoptive Child - if required by court 
.Verified Schedule 
.Child's Medical History 
.NYS Child Abuse & Maltreatment Registry Letter 
.Original Surrender(s) 
.Affidavit by Adoptive Parent(s) as to Receipt of Medical History of Adoptive Child 
.Completed Report of Investigation 
.Affidavit from Agency (if required by court) 
.Application for Certified Copy of Order (if required by court) 
.Proof that agency is authorized to place child in NYS Pursuant to Interstate Compact Agreement 
.Copy of Social History Form - that was given to attorney prior to filing of petition (if required by court) 
.Miscellaneous Documents received at time of surrender which may include but are not limited to: Affidavit Regarding Paternity, Affidavit of Financial Disclosure (from birth parent(s) surrendering child), Background Information Form, Religious Preference Form






111-a, 112(3), 384 
112(3)(6), 373-a 



If any of the documents submitted are in a foreign language, you must attach an English translation along with an Affidavit of Authority of Translator to act as same, and Certificate of Authorization by U.S. Consulate (if applicable).[see CPLR §2101(b)] 

Check to be certain all documents are properly acknowledged.

THIS MATERIAL IS PROVIDED FOR INFORMATIONAL/TRAINING PURPOSES ONLY. It is intended for use in conjunction with review of the applicable statute and rules of the Surrogate's Court and the Surrogate's Court Operations Manual.