SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT DOMESTIC RELATIONS BRANCH � ADOPTION ) ) ) ) ) ) ) ) ) ) ) ) EX PARTE IN THE MATTER OF PETITION OF [Petitioner #1] AND Case No. [Petitioner #2] FOR ADOPTION. PETITION FOR ADOPTION Petitioner(s) in this case is/are: [Petitioner #1 name] and [Petitioner #2 name] 1. This Court has jurisdiction pursuant to D.C. Code �16-301 because: Petitioner(s) is/are legal resident(s) of the District of Columbia and has/have resided in the District since on or about . Petitioner(s) has/have actually resided in the District of Columbia for at least one year immediately preceding the filing of the petition since on or about . the prospective adoptee is in the legal care, custody or control of the Mayor or a child-placing agency licensed under the laws of the District of Columbia. the prospective adoptee was born in the District of Columbia on or after July 18, 2009. Information about Petitioner(s) 2. Petitioner #1, [Name] , was born on [Date] and resides at [Address] . American LegalNet, Inc. www.FormsWorkFlow.com 3. Petitioner #1 is employed as follows: . [Occupation of Petitioner and the name of employer] 4. The race of Petitioner #1 is 5. Petitioner #2, [Name] and the religion is , was born on [Date] . . . and resides at [Address] 6. Petitioner #2 is employed as follows: . [Occupation of Petitioner and the name of employer] 7. The race of Petitioner #2 is 8. [If co-petitioners] and the religion is . Petitioner #1 and Petitioner #2 are: married domestic partners other 9. [If sole petitioner] . married. � unmarried. Petitioner is 10. During the past 10 years: the Petitioner(s) has/have not been a party in a personal capacity in any criminal, civil, or domestic matters. the Petitioner(s) has/have been a party in a personal capacity in the following criminal, civil, or domestic matters [provide caption, case number and name of court, if known]: . 11. [If the prospective adoptee is currently in foster care] An adoption subsidy agreement is is not being requested by the Petitioner(s). 12. The Petitioner(s) is/are fit and able to give the prospective adoptee a proper home and education and wish to treat the prospective adoptee as the Petitioner's/Petitioners' lawful child. � If the Petitioner is married, consent of the Petitioner's spouse is required. 2 American LegalNet, Inc. www.FormsWorkFlow.com Information about prospective adoptee� 13. The name of the prospective adoptee is female born on male ,a in . [City and State of birth, if known] [Date, if known] 14. The prospective adoptee is related to the Petitioner(s) as follows: . [Relationship] Petitioner is the prospective adoptee's step-parent (spouse/domestic partner of the prospective adoptee's parent) not related. 15. Petitioner(s) and prospective adoptee began residing together in the same home on or about . Petitioner(s) and the prospective adoptee are not residing together because . 16. The race of the prospective adoptee is 17. The religion of the prospective adoptee is 18. [if unknown, state "unknown"]. [if unknown, state "unknown"]. The prospective adoptee was placed with Petitioner(s) by a licensed child-placing agency. The agency is . The prospective adoptee was placed with Petitioner(s) as follows [brief description of circumstances]: . 19. During the past five years: there have been no other court actions involving the prospective adoptee. there are the following other court actions involving the prospective adoptee [provide the name of case, case number, and name of court, if known]: � A separate petition for adoption should be filed for each prospective adoptee 3 American LegalNet, Inc. www.FormsWorkFlow.com . 20. The combined assets of the prospective adoptee: do not exceed $3,000.00 exceed $3,000 [itemized list of child's assets]: . 21. The Interstate Compact on the Placement of Children is applicable and approval has been received. is applicable and approval has not been received. is not applicable. I/we do not know whether approval is necessary. 22. The Indian Child Welfare Act (25 U.S.C. �1901) is applicable and there has been compliance with the Act. is applicable and there has been compliance with the Act. is not applicable. I/we do not know whether the Act is applicable. 23. The Petitioner(s) has/have received has not/have not received medical, social and background information on the prospective adoptee. 24. The prospective adoptee is physically, mentally, and otherwise suitable for adoption by the Petitioner(s). 25. The petitioners wish that the name of the prospective adoptee: not be changed. be changed to Information about birth parents [If information is unknown, that should be stated.] . 26. The prospective adoptee's birth mother is She resides at 27. The prospective adoptee's birth father is He resides at 28. [If the birth parent(s) is/are unknown] The following efforts have been made to identify and locate the unknown birth parent(s): . . . . . 4 American LegalNet, Inc. www.FormsWorkFlow.com 29. There mother. 30. There father. 31. There is is not an executed original written consent to adoption by the birth is is not an executed original written consent to adoption by the birth is is not an order terminating the parental rights of the birth mother by a court of competent jurisdiction. is is not an order terminating the parental rights of the birth father by a court of competent jurisdiction. is is is not an affidavit by a putative father denying paternity. is not an affidavit by the birth mother that the birth father is unknown. 32. There 33. There 34. There 35. [If this is a step-parent adoption] partner 36. consents This is a step-parent adoption and my spouse/domestic does not consent. [If the prospective adoptee was conceived using artificial insemination] The prospective adoptee was conceived by a sperm donor other than the biological mother's spouse or domestic partner and, as such, no consent of the sperm donor is required. There adoption from the prospective adoptee. [If the prospective adoptee is 14 years of age or older] 37. is is not a written consent to the 38. [If the prospective adoptee was placed by a licensed child placement agency] The name and address of the agency responsible for securing any required consents or relinquishments is: . WHEREFORE, the Petitioner requests: 1. That the Court enter a final decree of adoption establishing the relationship of parent and child for all purposes between the Petitioner(s) and the prospective adoptee.