Form 16-A "Application for Certified Copy of Adoption Order" - New York

Form 16-A is a New York State Unified Court System form also known as the "Application For Certified Copy Of Adoption Order". The latest edition of the form was released in September 1, 2006 and is available for digital filing.

Download an up-to-date fillable Form 16-A in PDF-format down below or look it up on the New York State Unified Court System Forms website.

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Download Form 16-A "Application for Certified Copy of Adoption Order" - New York

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D.R.L. §114
Form 16-A
(Application for Certified
Copy of Adoption Order-
After sealing of records)
(9/2006)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF______________________
....................................................................
In the Matter of the Adoption of
(Docket)(File) No.
__________________
__________________________________
APPLICATION FOR
CERTIFIED COPY
OF ADOPTION
ORDER (After sealing
A Minor of the Age of
years
of records)
.....................................................................
The undersigned applicant(s) respectfully show(s) that:
1. The applicants)____________________________________________________________
(and)________________________________________________________________________
resides at _____________________________________________________(and)___________
____________(respectively) in the County of_____________________, State of____________
2. On or about the___day of _______________ ,
, an order was made by the Honorable
________________________________ , a judge of the _____________________Court of
__________________County, State of New York, approving the adoption of the above-named
child by ______________________ , and thereafter the order was duly filed in the office of the
Clerk of the ___________________________Court of the County of ____________________,
and sealed.
3. It is necessary for the applicant(s) to obtain a certified copy of the order approving the
adoption because of the following facts and circumstances [Explain. Note: if the applicant is a
Native-American individual 18 years of age or older who is seeking information and/or records
regarding the birth parents’ tribal affiliation, so indicate]:______________________________
____________________________________________________________________________
_______________________________________________.
WHEREFORE, applicant(s) request(s) that the Court make an order directing the Clerk of
the ____________________Court of the County of ____________________to prepare, certify
D.R.L. §114
Form 16-A
(Application for Certified
Copy of Adoption Order-
After sealing of records)
(9/2006)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF______________________
....................................................................
In the Matter of the Adoption of
(Docket)(File) No.
__________________
__________________________________
APPLICATION FOR
CERTIFIED COPY
OF ADOPTION
ORDER (After sealing
A Minor of the Age of
years
of records)
.....................................................................
The undersigned applicant(s) respectfully show(s) that:
1. The applicants)____________________________________________________________
(and)________________________________________________________________________
resides at _____________________________________________________(and)___________
____________(respectively) in the County of_____________________, State of____________
2. On or about the___day of _______________ ,
, an order was made by the Honorable
________________________________ , a judge of the _____________________Court of
__________________County, State of New York, approving the adoption of the above-named
child by ______________________ , and thereafter the order was duly filed in the office of the
Clerk of the ___________________________Court of the County of ____________________,
and sealed.
3. It is necessary for the applicant(s) to obtain a certified copy of the order approving the
adoption because of the following facts and circumstances [Explain. Note: if the applicant is a
Native-American individual 18 years of age or older who is seeking information and/or records
regarding the birth parents’ tribal affiliation, so indicate]:______________________________
____________________________________________________________________________
_______________________________________________.
WHEREFORE, applicant(s) request(s) that the Court make an order directing the Clerk of
the ____________________Court of the County of ____________________to prepare, certify
Adoption Form 16-A page 2
and deliver to the applicant(s) a copy of the original order of adoption granted herein, and for
such other and further relief as to the Court may be just and proper.
Applicant
Applicant
________________________________
Print or type name(s)
________________________________
Signature of Attorney, if any
________________________________
Attorney’s Name (Print or Type)
________________________________
________________________________
Attorney’s Address and Telephone Number
VERIFICATION
STATE OF NEW YORK
)
)ss.:
COUNTY OF_____________)
__________________________________________________, being duly sworn, say(s) that
(he)(she)(they)(is)(are) the applicants) above named; that (he)(she)(they)(have)(has) read the
foregoing application and the same is true to (his)(her)(their) knowledge except as to matters
therein stated to be alleged on information and belief and as to those matters (he)(she)(they)
believe(s) it to be true.
Applicant
Applicant
Subscribed and sworn to before me this_____
day of _________,______ .
(Deputy) Clerk of the Court
Notary Public
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