FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (CONSENT)CASE NUMBER FC-A NO. In the Matter of Adoption of A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:by [ ]the legal spouse of [ ]and [ ]the child(ren)'s legal parent [ ]husband and wife [ ]an unmarried person Petitioner(s). [ ]ATTORNEY FOR PETITIONER(S) [ ]PETITIONER(S) PRO SE NameAddressCity, State, Zip CodeTelephone Number TO THE PRESIDING JUDGE OF THE ABOVE-ENTITLED COURT: Comes now Petitioner(s) above-named alleging that: JURISDICTION/VENUE (HRS 247578-1): 1.The Family Court has jurisdiction and venue to grant this petition for adoption because:[ ]Petitioner(s) reside(s) or is/are stationed in the military service on the island on which this petition is being filed. [ ]The child(ren)/adult being adopted reside(s) or was born on the island on which this petition is being filed. [ ]The agency placing the child for adoption is licensed by the Department of Human Services and has its principal place of business on the island where this petition is being filed. 2.Petitioner(s) is/are:[ ]An unmarried person [ ]Married to the legal father or mother of the child(ren)/adult being adopted (Stepparent) [ ]Husband and Wife [ ]Other: Specify relationship: FOR COURT USE ONLY 08/07/01 PAGE 1 OF 3 PAGES PETITION FOR ADOPTION (CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (CONSENT) 3. INFORMATION REGARDING THE PETITIONER(S): PETITIONER PETITIONER Relationship to Adoptee Name (First, Middle, Last) Birth Name Street Address City, State, Zip Code Home Telephone Number Work Telephone Number Social Security Number Date of Birth Place of Birth # of Prior Marriages [ ]No [ ]Yes # Prior Marriages [ ]No [ ]Yes # Prior Marriages # of Criminal Convictions [ ]No [ ]Yes # Convictions [ ]No [ ]Yes # Convictions Prior Contact w/CPS [ ]No [ ]Yes [ ]No [ ]Yes Present Occupation Monthly Gross Income Date of Present Marriage # of Persons Living in Your Home 4. INFORMATION REGARDING THE CHILD Page 2A attached if more than one child Date of Birth Place of Birth Sex [ ]Male [ ]Female Racial Extraction Placed by Agency [ ]No [ ]Yes Name of Agency: Living w/Petitioner(s) Since Name after Adoption (First, Middle, Last) 08/07/01 PAGE 2 OF 3 PAGES PETITION FOR ADOPTION (CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (CONSENT) 4. INFORMATION REGARDING THE CHILD (continued): Date of Birth Place of Birth Sex [ ]Male [ ]Female Racial Extraction Placed by Agency [ ]No [ ]Yes Name of Agency: Living w/Petitioner(s) Since Name after Adoption (First, Middle, Last) INFORMATION REGARDING THE CHILD (continued): Date of Birth Place of Birth Sex [ ]Male [ ]Female Racial Extraction Placed by Agency [ ]No [ ]Yes Name of Agency: Living w/Petitioner(s) Since Name after Adoption (First, Middle, Last) INFORMATION REGARDING THE CHILD (continued): Date of Birth Place of Birth Sex [ ]Male [ ]Female Racial Extraction Placed by Agency [ ]No [ ]Yes Name of Agency: Living w/Petitioner(s) Since Name after Adoption (First, Middle, Last) 08/07/01 PAGE 2A OF 3 PAGES PETITION FOR ADOPTION (CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (CONSENT) 5. The Mother of the child(ren): [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] is not required to sign a Consent to Adoption as this is an adult adoption. 6. In regards to the father of the child(ren): The Natural Father of the child(ren): [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] is not required to sign a Consent to Adoption as this is an adult adoption. The Legal Only Father of the child(ren): [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] is not required to sign a Consent to Adoption as this is an adult adoption. 7. [ ] The adoptee(s) in this case is/are an adult and: [ ] The Adult Adoptee has signed a Consent to Adoption. [ ] The Adult Adoptee is married and his or her spouse has signed a Consent to Adoption. 8. Adoption of the child(ren)/adult(s) by the Petitioner(s) will be for the best interests of the child(ren)/adult(s). -------------------WHEREFORE, it is prayed that:(a) Upon a hearing, the child(ren)/adult(s) be decreed to be the legal child(ren) of the Petitioner(s), effective of as of the date of filing of this petition. (b) The name(s) of the child(ren)/adult(s) be decreed as set forth in paragraph numbered 4 above. (c) The Court decree such further relief as will serve the best interests of the child(ren). Under penalty of perjury, each Petitioner declares that Petitioner has read this petition for adoption and knows and understands the contents hereof, and that the statements made herein are true of Petitioner's own knowledge and belief. DATE SIGNATURE OF PETITIONER DATE SIGNATURE OF PETITIONER 08/07/01 PAGE 3 OF 3 PAGES PETITION FOR ADOPTION (CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com