Free D.R.L. § 115-c S.C.P.A.§ 1725 Form 21-E (Temporary Guardianship) 12/97 FAMIL... - New York

D.R.L. § 115-c S.C.P.A.§ 1725

Form 21-E (Temporary Guardianship) 12/97

FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF

In the Matter of the Temporary Guardianship of A Child Whose First Name is

(Docket)(File) No. AFFIDAVIT (Change of circumstance since certification as qualified adoptive parent)

STATE OF NEW YORK COUNTY OF

) :ss.. )

, being duly sworn depose(s) and say(s): 1. Deponent(s) (was)(were) certified as (a) qualified adoptive parent(s) by order of the Court, County of , dated 19 2.The following change(s) in circumstance relevant and material to such certification (has)(have) taken place since that date: Dated:
___________________________________ Petitioner ___________________________________ Print or type name ___________________________________ Signature of Attorney, if any ___________________________________ Attorney's Name (Print or Type) ___________________________________ ___________________________________ ___________________________________ Attorney's Address and Telephone Number

;

Sworn to before me this day of

, 19 .