Form 10-C "Affidavit Regarding Status of Appeal" - New York

What Is Form 10-C?

This is a legal form that was released by the Surrogate's Court of the State of New York - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2005;
  • The latest edition provided by the Surrogate's Court of the State of New York;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 10-C by clicking the link below or browse more documents and templates provided by the Surrogate's Court of the State of New York.

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D.R.L. §112
Adoption Form 10-C
(Affidavit Regarding
Status of Appeal –
Agency Adoption)
(9/2005)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _____________________________
.........................................................................................
In the Matter of the Adoption of
Docket No.______________
A Child Whose First Name Is:
AFFIDAVIT REGARDING
1
__________________________________________
STATUS OF APPEAL
.....................................................................................
STATE OF NEW YORK
)
)ss.:
COUNTY OF ____________)
I , [specify name]:_________________,_____________________________, an attorney
duly admitted to practice law in the State of New York, swear the following to be true under the
penalties of perjury:
1. I represented [specify authorized agency]:______________________________in the
following proceeding(s) that resulted in the above-named child being freed for adoption [specify
termination of parental rights and/or surrender proceeding(s)]: ____________________
2. The parental rights of the child’s birth mother were terminated as a result of [check
applicable box(es)]:
an order of disposition in a termination of parental rights proceeding, dated [specify]:
which was served upon the:
law guardian
counsel for the mother
mother, if self-represented; and
other parties [specify]:______________________________________________
[Check box if applicable]:
The order was not served upon the mother, because
she never appeared in the proceeding.
This order has not been reversed, modified or vacated and [check applicable box(es)]:
a notice of appeal has not been filed and the time to file a notice
has has not
lapsed.
a notice of appeal was filed and:
the appeal was dismissed as it was not perfected.
the appeal was not perfected and the time to perfect
has
has not
lapsed.
the appeal was perfected and has been disposed of as follows [specify]:
________________________________________________________________________
and
is
is not the subject of any further appeal or proceeding on
1
This form must be filed for all agency adoptions involving children freed for adoption by termination of
parental rights or surrender and should be completed by the attorney representing the agency in those proceedings.
D.R.L. §112
Adoption Form 10-C
(Affidavit Regarding
Status of Appeal –
Agency Adoption)
(9/2005)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _____________________________
.........................................................................................
In the Matter of the Adoption of
Docket No.______________
A Child Whose First Name Is:
AFFIDAVIT REGARDING
1
__________________________________________
STATUS OF APPEAL
.....................................................................................
STATE OF NEW YORK
)
)ss.:
COUNTY OF ____________)
I , [specify name]:_________________,_____________________________, an attorney
duly admitted to practice law in the State of New York, swear the following to be true under the
penalties of perjury:
1. I represented [specify authorized agency]:______________________________in the
following proceeding(s) that resulted in the above-named child being freed for adoption [specify
termination of parental rights and/or surrender proceeding(s)]: ____________________
2. The parental rights of the child’s birth mother were terminated as a result of [check
applicable box(es)]:
an order of disposition in a termination of parental rights proceeding, dated [specify]:
which was served upon the:
law guardian
counsel for the mother
mother, if self-represented; and
other parties [specify]:______________________________________________
[Check box if applicable]:
The order was not served upon the mother, because
she never appeared in the proceeding.
This order has not been reversed, modified or vacated and [check applicable box(es)]:
a notice of appeal has not been filed and the time to file a notice
has has not
lapsed.
a notice of appeal was filed and:
the appeal was dismissed as it was not perfected.
the appeal was not perfected and the time to perfect
has
has not
lapsed.
the appeal was perfected and has been disposed of as follows [specify]:
________________________________________________________________________
and
is
is not the subject of any further appeal or proceeding on
1
This form must be filed for all agency adoptions involving children freed for adoption by termination of
parental rights or surrender and should be completed by the attorney representing the agency in those proceedings.
Adoption Form 10-C
Page 2
remand pending in any Court;
a surrender of the child, dated [specify]:_________________________________________
The surrender has not been revoked or vacated and [check applicable box(es)]:
it is not the subject of revocation proceedings.
revocation proceedings were brought but were disposed of as follows [specify]:
________________________________________________________________________
a notice of appeal has not been filed and the time to file a notice
has has not
lapsed.
a notice of appeal was filed and:
the appeal was dismissed as it was not perfected.
the appeal was not perfected and the time to perfect
has has not
lapsed.
the appeal was perfected and has been disposed of as follows [specify]:
________________________________________________________________________
and
is
is not the subject of any further appeal or proceeding on
remand pending in any Court;
3. The parental rights of the child’s birth father or any other individual entitled to consent to
the adoption were terminated as a result of [check applicable box(es)]:
an order of disposition in a termination of parental rights proceeding, dated [specify]:
________________which was served upon the:
law guardian
counsel for the father
father, if self-represented; and
other parties [specify]: _____________________________________________
[Check box if applicable]:
The order was not served upon the father because
he never appeared in the proceeding.
This order has not been reversed, modified or vacated and [check applicable box(es)]:
a notice of appeal has not been filed and the time to file a notice
has has not
lapsed.
a notice of appeal was filed and:
the appeal was dismissed as it was not perfected.
the appeal was not perfected and the time to perfect
has has not
lapsed.
the appeal was perfected and has been disposed of as follows [specify]:
________________________________________________________________________
and
is
is not the subject of any further appeal or proceeding on
remand pending in any Court;
a surrender of the child, dated [specify]: _________________________________________
The surrender has not been revoked or vacated and [check applicable box(es)]:
it is not the subject of revocation proceedings.
revocation proceedings were brought but were disposed of as follows [specify]:
________________________________________________________________________
a notice of appeal has not been filed and the time to file a notice
has has not
lapsed.
a notice of appeal was filed and:
Form SURR-3
Page 3
the appeal was dismissed as it was not perfected.
the appeal was not perfected and the time to perfect
has has not
lapsed.
the appeal was perfected and has been disposed of as follows [specify]:
________________________________________________________________________
and
is
is not the subject of any further appeal or proceeding on
remand pending in any Court;
__________________________________________
Signature of Attorney, if any
__________________________________________
Attorney’s Name (print or type)
__________________________________________
__________________________________________
__________________________________________
Attorney’s Address and Telephone Number
Sworn to before me this
day of _____,___.
_______________________
(Deputy) (Clerk of the Court)
(Notary Public)
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