ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address) Reserved for Clerk's Office Stamp TELEPHONE NO: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO Youth Services Center, Juvenile Court 222 Paul Scannell Drive San Mateo, CA 94402 IN RE: CASE NUMBER: ADULT ADOPTION AGREEMENT Adopting parent(s) (print name) a. _____________________________________________ b.________________________________________ (first, middle, last) (first, middle, last) Person to be adopted name before adoption:_______________________________________________ (first, middle, last) Male Female Date of Birth: __________________________Age:___________ Person to be adopted name after adoption: (print name clearly) ____________________________ ________________________ _________________________________________ (first) (middle) (last) The following will be completed in Court before the Judge, DO NOT sign in advance. We, the undersigned, agree with the State of California to assume towards each other the legal relationship of parent and child and to have all of the rights and be subject to all of the duties and responsibilities of that relationship. ___________________________________ (Type or Print Name) ____________________________________________ (Signature of Adopting Parent) ___________________________________ (Type or Print Name) ____________________________________________ (Signature of Adopting Parent) ___________________________________ (Type or Print Name) ____________________________________________ (Signature of Adoptee) Date: __________________ ____________________________________________ Judge of the Superior Court Form adopted for Mandatory Use Local Court Form Adopt-5 [Revised Sept. 2012] Adult Adoption Agreement www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com