[Attorney Caption: name, address, zip code, telephone #, ID #] IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ PETITION FOR INVOLUNTARY TERMINATION OF PARENTAL RIGHTS INDIVIDUAL PETITION Petition of _________________________ under § 2512 of the Adoption Act: 1. [Petitioner(s)' name(s), address(es) and standing and relationship to child.] 2. [Child's name, age, date of birth, racial background, sex and religious affiliation.] 3. The facts as to the birth parents of the child are: a. Mother: 1) [Name] 2) [Address] 3) [Age] 4) [Racial background] 5) [Religious affiliation] b. Father: 1 1) [Name] 2) [Address] 3) [Age] 4) [Racial background] 5) [Religious affiliation] 4. 1) [Marital status as of the time of the birth of the child] 2) [Marital status during one year prior to the birth of the child] 3) [If ever married: name(s) of husband(s); maiden name] 5. [Date child was placed in care of Petitioner(s).] 6. [Facts constituting grounds for termination. (Identify specific subsection of § 2511(a) of Adoption Act.)] 7. [State whether either parent is entitled to benefits of the Soldiers' and Sailors' Civil Relief Act of 1940, as amended (50 USCA §501 et seq.).] 8. Petitioner(s) will assume custody of the child until such time as the child is adopted. WHEREFORE, Petitioner(s) pray(s) y our Honorable Court for a finding of involuntary termination of parental rights of _____________________ (and) , and for a decree terminating all parental rights of _____________________ If father n ot identified, state whet her acknowledgment or claim of p aternity has been filed pursuant to 23 Pa. C.S.A. § 5103(b) and explain why birth father is unknown. 1 American LegalNet, Inc. www.FormsWorkFlow.com (and) ] in respect to ______________________, awarding custody of the child to Petitione r(s), and authorizing him /her/them to consent to the adoption of _______________________. [Signature] [Type Name] [Signature] [Type Name] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, _______________________ verify that I am the Peti tioner named in the foregoing Petition and that the facts set forth therein are true and correct, to the best of my knowledge, information, and belief. I under stand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 r elating to unsworn falsification to authorities. ___________[Signature]____________________ ________________________ _______________ American LegalNet, Inc. www.FormsWorkFlow.com