STATE OF HAWAI‘I FAMILY COURT OF THE ________ CIRCUIT CASE NUMBER STATEMENT OF MAILING; EXHIBITS “1” AND “2” ❑ ❑ In the Matter of Adoption of A ❑ MALE ❑ FEMALE CHILD Born on: A ❑ MALE ❑ FEMALE CHILD PETITIONER(S) PRO SE _________________________________________________ ❑ FEMALE CHILD ❑ FEMALE CHILD _________________________________________________ Address Born on: A ❑ MALE ATTORNEY FOR PETITIONER(S) _________________________________________________ Name Born on: A ❑ MALE FC-A NO. _________________________________________________ City, State, Zip Code Born on: _________________________________________________ Telephone Number by: ❑ the legal spouse of ❑ and ❑ the child(ren)’s legal parent ❑ husband and wife ❑ an unmarried person Petitioner(s). I represent that the following documents was served on the person listed below: ❑ Certified copy of the Petition for Adoption (Non-Consent) and attachment ❑ Other: by certified mail, return receipt requested. At the time of mailing, the receipt attached as Exhibit “1” was received; and in due course, the return receipt attached hereto as Exhibit “2” was received. The person served was: NAME: _______________________________________________________________________________________ ADDRESS: ___________________________________________________________________________________ ____________________________________________________________________________________________ CITY, STATE, ZIP CODE: ________________________________________________________________________ DATE SIGNATURE OF ATTORNEY OR PETITIONER In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit Court Administration Office at PHONE NO. 539-4333, FAX 539-4322, OR TTY 539-4853 at least ten (10) working days prior to your hearing or appointment date. (07/06) Reprographics PAGE 1 OF 2 STATEMENT OF MAILING; EXHIBITS 1 AND 2 (FC-A) 1F-P-699 American LegalNet, Inc. www.FormsWorkflow.com STATE OF HAWAI‘I FAMILY COURT OF THE _______ CIRCUIT CASE NUMBER STATEMENT OF MAILING; EXHIBITS “1” AND “2” FC-A NO. EXHIBIT 1 EXHIBIT 2 In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit Court Administration Office at PHONE NO. 539-4333, FAX 539-4322, OR TTY 539-4853 at least ten (10) working days prior to your hearing or appointment date. (07/06) Reprographics PAGE 2 OF 2 STATEMENT OF MAILING; EXHIBITS 1 AND 2 (FC-A) 1F-P-699 American LegalNet, Inc. www.FormsWorkflow.com