FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I ADOPTION HEARING FLAG SHEET CASE NUMBER FC-A No. In the Matter of the Adoption of A [ ] MALE Born on: A [ ] MALE Born on: A [ ] MALE Born on: A [ ] MALE Born on: by [ ] FEMALE CHILD, [ ] FEMALE CHILD, [ ] FEMALE CHILD, [ ] FEMALE CHILD, [ ] ATTORNEY FOR PETITIONER(S) [ ] PETITIONER(S) PRO SE Name Address City, State, Zip Code Telephone Number [ ] legal spouse of [ ] civil union partner of [ ] and E-Mail Address [ ] the child(ren)'s legal parent [ ] a married couple [ ] civil union partners [ ] an unmarried person Petitioner(s). I. Type of Adoption: (`x' all that apply) [ ] Consent [ ] Non-Consent [ ] Step-parent [ ] Relative: [ ] Agency: (Name of Agency) (Relationship to Child) II. Consent(s) have been obtained from the following person(s)/agency: (`x' all that apply) [ ] Mother [ ] Legal Only Father [ ] Child(ren) 10 years and older [ ] Natural and Legal Father [ ] Legal Guardian(s) [ ] Agency: [ ] Natural/Adjudicated Father [ ] Legal Custodian(s) [ ] Other: III. Consent(s) have not been obtained from the following person(s)/agency: (`x' all that apply) [ ] Mother [ ] Legal Only Father [ ] Child(ren) 10 years and older [ ] Natural and Legal Father [ ] Legal Guardian(s) [ ] Agency: [ ] Natural/Adjudicated Father [ ] Legal Custodian(s) [ ] Other: IV. Consent(s) of person(s) in paragraph III may be dispensed with and is not required because: In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the Family Court Service Center, at 954-8290, if you have any questions about procedures or how to fill out this form. Ho`okele/FC Adm 11/10/16 Page 1 of 2 Pages COURT USE ONLY ADOPTION HEARING FLAG SHEET 1F-P-1044 American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I V. ADOPTION HEARING FLAG SHEET CASE NUMBER FC-A No. The following exhibits/documents have been filed: [ ] Certified copy of each child's birth certificate [ ] Petitioner's marriage certificate [ ] Marriage certificate of adult adoptee [ ] Death Certificate for child(ren)'s [ ] mother [ ] father [ ] Divorce Decree for: (name which Petitioner) [ ] Order Appointing Legal Custodian or Guardian of the child(ren) [ ] Paternity Judgment for child(ren) [ ] Certified copy of the Judgment of Termination of Parental Rights [ ] Certified copy of the Order Awarding Permanent Custody [ ] Affidavit of Birth Background [ ] Foreign Adoption Placement Agency's Affidavit [ ] Medical certificate for each child [ ] Statement of Mailing of Notice to DHS (Department of Human Services) Have any foreign language documents been translated into English? [ ] Yes [ ] No The following documents have been given to the Adoption Clerk: [ ] DOH Medical Information form, Birth Parent's Consent to Release of Information [ ] Mother's medical records of the child(ren)'s birth and Mother's Consent to Release [ ] Copy of Adoption Information Sheet List any missing documents, which are required by statute, rule, or official memorandum: VI. VII. VIII. IX. X. XI. Does Interstate Compact on the Placement of Children (ICPC) apply? If yes, have all the requirement of ICPC been met? [ ] Yes [ ] No [ ] Yes [ ] No Does the Indian Child Welfare Act (ICWA) apply to this case? [ ] Yes [ ] No [ ] Yes [ ] No If yes, have all requirements of ICWA been met? Are you aware of any opposition or objection to the Petition? [ ] Yes [ ] No If yes, by whom (include relationship to child(ren) and reason(s) for objection, if known) The undersigned Attorney or Petitioner(s) Pro Se hereby certifies that to the best of his or her knowledge and belief, all of the foregoing are true and correct. DATE SIGNATURE OF ATTORNEY OR PETITIONER PRO SE DATE SIGNATURE OF ATTORNEY OR PETITIONER PRO SE Ho`okele/FC Adm 11/10/16 Page 2 of 2 Pages ADOPTION HEARING FLAG SHEET 1F-P-1044 American LegalNet, Inc. www.FormsWorkFlow.com