FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (NON-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 NumberATTACHMENTS: [ ] SUPPORTING AFFIDAVIT [ ] [ ] ORDER FOR SERVICE BY ( )MAIL ( ) PUBLICATION ( )PERSONAL SERVICE WITHOUT THE STATE [ ] NOTICE OF TIME AND PLACE OF HEARING [ ] SUMMONS 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) 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) being adopted (Stepparent) [ ]Husband and Wife [ ]Other: Specify relationship: FOR COURT USE ONLY 08/07/01 PAGE 1 OR 4 PAGES PETITION FOR ADOPTION (NON-CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (NON-CONSENT) CASE NUMBER FC-A NO. 3. INFORMATION REGARDING THE PETITIONERS: 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 Number of Prior Marriages [ ]No [ ]Yes # Prior Marriages [ ]No [ ]Yes # Prior Marriages Number of Criminal Convictions [ ]No [ ]Yes # Convictions [ ]No [ ]Yes # Convictions Contact w/Child Protective Services [ ]No [ ]Yes [ ]No [ ]Yes Present Occupation Monthly Gross Income Date of Present Marriage Number 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 4 PAGES PETITION FOR ADOPTION (NON-CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (NON-CONSENT) CASE NUMBER FC-A NO. 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) American LegalNet, Inc. www.FormsWorkFlow.com 08/07/01 PAGE 2A OF 4 PAGES PETITION FOR ADOPTION (NON-CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (NON-CONSENT) CASE NUMBER FC-A NO. 5. 6. 7. The Mother of the child(ren): [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] has not consented to the adoption of the child(ren), but her consent is not required or may be dispensed with pursuant to the grounds reflected in paragraph 7 below. In regards to the Father(s) of the child(ren): The Natural Father of the child(ren): [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] has not consented to the adoption of the child(ren), but his consent is not required or may be dispensed with pursuant to the grounds reflected in paragraph 7 below. The Legal Only Father of the child(ren): [ ]Not Applicable [ ] has signed a Consent to Adoption. [ ] is deceased. [ ] has not consented to the adoption of the child(ren), but his consent is not required or may be dispensed with pursuant to the grounds reflected in paragraph 7 below. Mother's and/or Father's consent to the adoption is not required or may be dispensed with because: [ ] ( )Father ( )Mother has deserted the child(ren) for a period of at least ninety 90) days. HRS 247578-2(c)(1)(A) [ ] ( )Father ( )Mother has voluntarily surrendered the care and custody of the child(ren) to another for a period of two (2) years. HRS 247578-2(c)(1)(B) [ ] ( )Father ( )Mother has failed to communicate with the child(ren) for a period of at least one (1) year when able to do so. HRS 247578-2(c)(1)(C) [ ] ( )Father ( )Mother has failed to provide for the care and support of the child(ren) for a period of at least one (1) year when able to do so. HRS 247578-2(c)(1)(D) [ ] The natural father, was not married to the mother of the child(ren), and he is not an adjudicated, presumed or concerned father. HRS 247578-2(c)(1)(E) [ ] ( )Father ( )Mother had his or her parental rights judicially terminated by a court of competent jurisdiction. HRS 247578-2(c)(1)(F) [ ] ( )Father ( )Mother had his or her parental and custodial rights divested by an award of permanent custody pursuant to HRS 247587-73. HRS 247578-2(c)(1)(K) [ ] Other grounds pursuant to HRS 247578(c)(1) and/or (2): 08/07/01 PAGE 3 OF 4 PAGES PETITION FOR ADOPTION (NON-CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I PETITION FOR ADOPTION (NON-CONSENT) CASE NUMBER FC-A NO. 8. The Legal Custodian or Legal Guardian(s) of the child(ren): [ ]Not applicable. [ ] signed a Consent allowing the child(ren) to be adopted. [ ] has not consented to the adoption of the child(ren). 9. If parental rights have not been terminated or divested previously, due notice of the foregoing allegations and of the time and place of hearing of this petition for adoption will be given to the non-consenting Parent(s), Legal Custodian or Legal Guardian by: [ ] personal service. [ ] certified or registered mail. [ ] publication. 9. Adoption of the child(ren) by the Petitioner(s) will be in the best interest of the child(ren). WHEREFORE, it is prayed that: (a) If parental rights have not been terminated or divested previously, notice of the pendency of this petition for adoption and of the time and place of hearing be given to the non-consenting Parent(s), Legal Custodian or Legal Guardian in the manner indicated in paragraph 9 above. (b) Upon a hearing, the child(ren) be decreed to be the legal child(ren) of the Petitioner(s), effective of as of the date of filing of this petition. (c) The name(s) of the child(ren) be decreed as set forth in paragraph numbered 4 above. (d) The Court decree such further relief as will serve the best interest 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 4 OF 4 PAGES PETITION FOR ADOPTION (NON-CONSENT) American LegalNet, Inc. www.FormsWorkFlow.com