[ ] Petitioner(s), Pro Se [ ] Attorney for Petitioner(s) IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAI`I In the Matter of Adoption of ) FC-A NO. A [ ]MALE [ ]FEMALE ) Born on: ) PETITION FOR ADOPTION A [ ]MALE [ ]FEMALE ) (CONSENT) Born on: ) A [ ]MALE [ ]FEMALE ) Born on: ) A [ ]MALE [ ]FEMALE ) Born on: ) ) by ) ) ) [ ] the legal spouse of [ ] and ) ) ) [ ] the child(ren)222s legal parent ) [ ] husband and wife [ ] civil union partners ) [ ] an unmarried person ) ) Petitioner(s) ) PETITION FOR ADOPTION (CONSENT) 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. American LegalNet, Inc. www.FormsWorkFlow.com [ ] The child(ren)/adult being adopted reside(s) or was born on the island which this petition is being filed. [ ] The agency placing the child for 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 (Step-Parent) [ ] Husband and Wife [ ] Civil Union Partners [ ] Other: (specify relationship): 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 Date of Present Marriage/Civil Union American LegalNet, Inc. www.FormsWorkFlow.com 4. INFORMATION REGARDING THE CHILD: Date of Birth Place of Birth S ex [ ] Male [ ] Female Racial Extraction Placed by Agency [ ] No [ ] Yes Name of Agency: Living w/Petitioner(s) Since Name After Adoption (First, Middle, Last) 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) 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) American LegalNet, Inc. www.FormsWorkFlow.com 4. INFORMATION REGARDING THE 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) 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(s) 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). American LegalNet, Inc. www.FormsWorkFlow.com 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 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 number 4 above. (c) The Court decrees such futher 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 Petitioner222s own knowledge and belief. DATE SIGNATURE OF PETITIONER DATE SIGNATURE OF PETITIONER In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require an accommodation for a disability, please contact the ADA Coordinator at the Family Court Administration Office at PHONE NO. 244-2700, FAX 244-2704 OR email adarequest@courts.hawaii.gov at least ten (10) working days before your proceeding, hearing or appointment date. American LegalNet, Inc. www.FormsWorkFlow.com