IN THE FAMILY COURT OF THE ________CIRCUIT STATE OF HAWAII FC-A NO. In the Matter of the Adoption of A MALE/FEMALE CHILD, Born on by Petitioner(s). THE STATE OF HAWAI‘I TO: , whose last known address is: YOU ARE HEREBY NOTIFIED that a petition for adoption of the above-identified child(ren) born to , the child(ren)’ s mother, has been filed in the Family Court, First Circuit, State of Hawai‘i. THE PETITION ALLEGES that your consent to the adoption of the above-named child(ren) by the Petitioner(s) above-named is not required and may be dispensed with pursuant to Hawai‘i Revised Statutes Section 578-2(c) as amended. A hearing on the Petition will be held on at .m. at the Family Court located at the Ka‘ahumanu Hale, 777 Punchbowl Street, Second Floor, Honolulu, Hawai‘i. IF YOU FAIL to appear at the hearing on date and time and at the place noted above or if you fail to file a written response to the allegations reflected in the Petition for Adoption, further action may be taken including the granting of the adoption without further notice to you. Your written response should be addressed to the Presiding Judge, Family Court, First Circuit, 777 Punchbowl Street, Second Floor, Honolulu, Hawai‘i 96813 Page 1 of 2 Pages American LegalNet, Inc. www.FormsWorkflow.com (mailing address: P. O. Box, Honolulu, Hawai‘i 96811). FAILURE TO OBEY this notice may result in an entry of a default and default judgment against you. YOU ARE FURTHER NOTIFIED that the child, the adoptive parents and the natural parents have rights under H.R.S. Section 578-15 regarding confidentiality of adoption records after the child reaches age 18. DATED: Honolulu, Hawaii, . Clerk of the above-entitled Court Attorney/Petitioner(s)’s Name: Address: Name of Newspaper: Page 2 of 2 Pages American LegalNet, Inc. www.FormsWorkflow.com