[ ] 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 ) (NON-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 (NON-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 [ ] 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. [ ] has not consented to the adoption of the child(ren), but her consent is not required or may be dispensed with pursuant the grounds reflected in paragraph 7 below. 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. [ ] has not consented to the adoption of the child(ren), but her consent is not required or may be dispensed with pursuant 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 her consent is not required or may be dispensed with pursuant the grounds reflected in paragraph 7 below. American LegalNet, Inc. www.FormsWorkFlow.com 7. Mother222s and/or Father222s consent to the adoption is not required or may be dispensed 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 247578-73. HRS 247578-2(c)(1)(K) [ ] Other grounds pursuant to HRS 247578-2(c)(1) and/or (2): 8. The Legal Custodian or Legal Guardian(s) of the children: [ ] 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. 10. Adoption of the child(ren) by the Petitioner(s) will be for the best interests of the child(ren). American LegalNet, Inc. www.FormsWorkFlow.com 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 as of the date of filing of this petition. (b) The name(s) of the child(ren) be decreed as set forth in paragraph number 4 above. (c) The Court decrees 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 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