FAMILY COURT ____________ CIRCUIT STATE OF HAWAI‘I ADOPTION HEARING FLAG SHEET CASE NUMBER FC-A NO. [ ]ATTORNEY FOR PETITIONER(S) [ ]PETITIONER(S) PRO SE 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: Name by Address City, State, Zip Code [ ]the legal spouse of [ ]and Telephone Number [ ]the child(ren)'s legal parent [ ]husband and wife [ ]an unmarried person Petitioner(s). I. Type of Adoption: (‘x’ all that apply) [ ]Consent [ ]Non-Consent [ ] Stepparent [ ]Relative (Relationship to Child) [ ] Agency (Name of Agency) II. Consent(s) have been obtained from the following person(s)/agency: (‘x’ all that apply) [ ] Mother [ ] Legal Guardian(s) [ ] Natural and Legal Father [ ] Legal Custodian [ ] Natural/Adjudicated Father [ ] Agency: [ ] Legal Only Father [ ] Child(ren) 10 years old and over) [ ] Other III. Consent(s) have not been obtained from the following person(s)/agency: (‘x’ all that apply) [ ] Mother [ ] Legal Guardian(s) [ ] Natural and Legal Father [ ] Legal Custodian [ ] Natural/Adjudicated Father [ ] Agency: [ ] Legal Only Father [ ] Child(ren) 10 years old and over) [ ] Other IV. Consent(s) of person(s) is paragraph III may be dispensed with and is not required because: 09/18/01 PAGE 1 OF 2 PAGES ADOPTION HEARING FLAG SHEET American LegalNet, Inc. www.FormsWorkflow.com FAMILY COURT ______ CIRCUIT STATE OF HAWAI‘I ADOPTION HEARING FLAG SHEET V. 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 [ ]male petitioner [ ]female petitioner [ ] Order Appointing Legal Custodian or Guardian of the child(ren) [ ] Paternity Judgment for child(ren) [ ] Certified copy Judgment of Termination of Parental Rights [ ] Certified copy of 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 VI. Have any foreign language documents been translated into English? [ ]Yes [ ]No VII. The following documents have been given to the adoption clerk: [ ] [ ] [ ] VIII. 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 the Adoption Information Sheet List any missing documents, which are required by statute, rule or official memorandum: . IX. Does Interstate Compact on the Placement of Children (ICPC) apply? [ ]Yes [ ]No If yes, have all requirements of ICPC been met? [ ]Yes [ ]No X. Does the Indian Child Welfare Act (ICWA) apply to this case? [ ]Yes [ ]No If yes, have all requirements of ICWA been met? [ ]Yes [ ]No XI. Are you aware of any opposition or object to the Petition? [ ]Yes [ ]No If yes, by whom (include relationship to child(ren) and reason by objection, if known): . The undersigned attorney or petitioner pro se hereby certifies that to the best of his or her knowledge and belief, all of the foregoing are true and correct. DATE 08/07/01 SIGNATURE OF ATTORNEY OR PETITIONER PRO SE PAGE 2 OF 2 PAGES ADOPTION HEARING FLAG SHEET American LegalNet, Inc. www.FormsWorkflow.com