NY NOTICE OF PROPOSED ADOPTION TEMPLATE

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					D.R.L. §§ 111(3), 111-a(6),115(9).                             Adoption Form 4
                                                               (Notice of Proposed Adoption)
                                                               10/2004


FAMILY COURT OF THE STATE OF NEW YORK
COUNTY OF
 _________________________________
In the Matter of the Adoption of                                G Docket G File No.
A Child whose First Name is
                                                                NOTICE OF PROPOSED
                                                                    ADOPTION


_________________________________

To:


       PLEASE TAKE NOTICE that a petition requesting an order approving and allowing
the adoption of an adoptive child whose first name is [specify]:                     , who is
alleged to be your [specify relationship]:                         , and whose full name and
date and place of birth is set forth in a Schedule annexed to the petition for adoption herein,
together with an agreement to adopt and consents to the adoption pursuant to the Domestic
Relations Law, has been filed with the [specify]:                  Court of the State of New
York,                County. A hearing on the petition will be held at the Court, located at
[specify address]:
on [specify date]:         , at [specify time]:      o'clock in the G morning G afternoon of
that day, at which time and place all persons having any interest therein will be heard.


       [Check box if applicable pursuant to Domestic Relations Law §111-a(6)]:
        Q PLEASE TAKE FURTHER NOTICE that your failure to appear may constitute a
denial of your interest in the child, which may result, without further notice to you, in the
adoption or other disposition of the custody of the child.



                                            Signature of Petitioner’s Attorney
                                             __________________________
                                            Attorney’s Name (print or type)
                                            ___________________________
                                            ___________________________
                                            Attorney’s Address and Telephone Number

				
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