CONNECTICUT PROBATE COURTS Adoption Data Sheet PC-680 R 7/18 CONFIDENTIAL Adoption Data Sheet PC - 680 Page 1 of 2 Instructions: 1) The statutory parent, child-placing agency or a person giving a child in adoption may use this form to provide information about the parents who are deceased or whose rights were terminated and adoptive parents of a minor child in an adoption proceeding. 2)This form shall be filed in duplicate with a) the petition for appointment of a statutory parent or foradoption, b) a certified copy of the long form birth certificate of the minor child 3) documents in support of the petitioner222s representation that the child is free for adoption, including certified decrees and/or certified death certificates and 4) Record of Adoption (Department of Public Health form, VS-51). 3 )Type or print the form i n ink. Probate Court Name District Number In the Matter of (Full name and address) Hereinafter referred to as the minor child. Date of Birth of Minor Child Place of Birth of Minor Child Proposed Name of Minor Child after Adoption Name of Minor Child on Birth Certificate The child is free for adoption because the parental rights of the following parents have been terminated or the parents are deceased: Parent (Full name and address) Parent (Full name and address) Date of Birth If deceased, give date and place of death. Date of Birth If deceased, give date and place of death If parental rights were terminated, list court and decree date. If parental rights were terminated, list court and decree date. Statutory Parent (Name and ddress of ain or ocal ffice) Court-appointed Guardian of the Person of Minor Date of Appointment Date of Appointment Court of Appointment Court of Appointment Adoptive Parent (Full ame and ddress) Adoptive Parent (Full ame and ddress) Telephone number Telephone number Date of Birth Date of Birth Relationship to child Relationship to child Date and place of marriage of adopting parents, if applicable American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Adoption Data Sheet PC-680 R 7/18 CONFIDENTIAL Adoption Data Sheet PC - 680 Page 2 of 2 THE SUBSCRIBER REPRESENTS THAT the foregoing information submitted in connection with the petition for approval of the Adoption Agreement concerning the minor child is true to the best of my knowledge and belief. The representations made in this petition are made under the penalty of false statement. Signature of Subscriber Title ype Name Date American LegalNet, Inc. www.FormsWorkFlow.com