Reserved for Clerk’s Office Stamp ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address) 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 REQUEST 1. Name(s) of adopting parent(s) (please use full legal name): a. __________________________________________________________ b. __________________________________________________________ Your address: Street: ___________________________________________________________________ City: __________________________ State: _______ Zip: ___________________ Phone number: ( ) _____________________________ Email address ____________________________________________ Your lawyer (if you have one): (Name, address, phone number ,State Bar number) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ 2. Person to be adopted (name): ______________________________________________________  Male  Female Date of Birth: __________________________ Age:___________ Street: __________________________________________________________ City: ______________________________ State: _______ Zip: ____________ Page 1 of 3 Form adopted for Mandatory Use Local Court Form ADOPT-4 [Revised 9-2012] ADULT ADOPTION REQUEST www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com 3. The adoptive parent(s) is/are older than the adult to be adopted.  Yes  No 4. The adoptive parent  is  is not the spouse of the adult to be adopted. 5.  The adoptive parent and adult to be adopted are related as: ________________________________ (describe family relationship) and have resided together as parent and child for _________________________.(state number of year(s)/month(s)) 6.  The adoptive parent and adult to be adopted are not related as family, but have established the following relationship (describe relationship and length): _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 7. We are asking for the adoption because (state reasons, attach additional pages if necessary ): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 8. The adoption is in the best interest of the adult to be adopted, the adopting parent(s) and the public because (state reasons, attach additional pages if necessary): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 9.  The mother of the adult to be adopted is still living. Her name and address if known are: Name: __________________________________________________________________ Street: __________________________________________________________________ City: __________________________ State: _______ Zip: _______________ 10.  The father of the adult to be adopted is still living. His name and address if known are: Name: __________________________________________________________________ Street: __________________________________________________________________ City: __________________________ State: _______ Zip: _______________ Page 2 of 3 Form adopted for Mandatory Use Local Court Form ADOPT-4 [Revised 9-2012] ADULT ADOPTION REQUEST www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com 11. The  mother  father of the adult to be adopted is deceased. 12. If there are any living adult children of the adopting parent(s) you must list their names and addresses below. (attach additional pages if necessary): Name: _________________________________________________________________________ Street: _________________________________________________________________________ City: __________________________ State: _______ Zip: _______________  Additional page(s) attached 13. If the adopting parent(s) has/have adopted other adult(s) you must list name(s) and date(s) and place(s) of the adoption(s). You may only adopt one unrelated adult in a 12 month period. (attach additional pages if necessary): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________  Additional page(s) attached 14.  The adult to be adopted is married and their spouse is in agreement with the adoption as stated on the Local Form, Adopt-11. 15.  My spouse is not adopting the adult listed in section 2 but is in support of the adoption as stated on the Local Form, Adopt-11. 16. Petitioners request the court to grant the request for adoption and to declare that each petitioning adoptive parent and the adult to be adopted shall sustain toward one another the legal relationship of parent and child, with all the rights and duties of the relationship. 17. Petitioners request that the adopted adult’s name  remain the same  be changed to: (type or print the full adoptive name): _______________________ ____________________ ______________________________ (first) (middle) (last) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: _ _________________ _____________________ __________________________________ (Type or Print Name) Date: _ _________________ _____________________ (Signature of Adopting Parent) __________________________________ (Type or Print Name) Date: _ _________________ (Signature of Adopting Parent) _____________________ __________________________________ (Type or Print Name) (Signature of Adult to be Adopted) Page 3 of 3 Form adopted for Mandatory Use Local Court Form ADOPT-4 [Revised 9-2012] ADULT ADOPTION REQUEST www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com