STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) PETITION FOR ADOPTION AND CHANGE OF NAME 4 M.R.S. � 152(5-A) (Name of Petitioner) (Name of Co-Petitioner) 1. Petitioner Information: Name: Legal residence: Mailing address: Telephone: 2. Co-Petitioner Information: Name: Legal residence: Mailing address: Telephone: 3. Adoptee Information: Date of birth: Place of birth: Birth name: Other names: Proposed new name: With whom and where does adoptee reside: Date of birth: Date of birth: Date/Place of marriage: Date/Place of marriage: 4. The court has jurisdiction because (choose A or B): A. The adoptee IS placed by a licensed child placing agency or the Department of Health and Human Services ("DHHS") and: Petitioner(s) resides in this county. Adoptee resides or was born in this county. An office of the agency that placed the adoptee for adoption or of DHHS is located in this county. AD-001 07/16 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com  B. The adoptee IS NOT placed by a licensed child placing agency or DHHS and: Adoptee resides in this county. Petitioner(s) resides in this county. Consent to this adoption has been or will be filed in this county. 5. Adoptee is in Legal Custody of (choose one): , a licensed child placing agency pursuant to a court order or a duly executed and lawful surrender and release. DHHS pursuant to a court order or a duly executed and lawful surrender and release. Petitioner(s). (Attach all documents proving legal custody, including divorce decrees or other court order.) Other. Explain: 6. (CHOOSE ONE) A certified copy of the birth record of the adoptee is attached; A delayed birth registration of the adoptee is attached; OR The following steps will be taken to secure and file a birth record or delayed birth registration before the hearing: 7. List names and addresses of all persons or agencies known to the petitioner(s) that affect the custody, visitation or access to the adoptee. Explain the relationship of each to the adoptee: 8. Identify the relationship, if any, of petitioner(s) to the adoptee: 9. Address of the office of DHHS involved with this adoption, if any: 10. Name and address of the licensed child placing agency involved with this adoption, if any: AD-001 07/16 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com  11. Consent to the adoption is required from the following (check all that apply): Adoptee (if 14 years of age or older) Attached Mother Attached Father Attached Other Attached Guardian or legal custodian of adoptee Attached DHHS or other appropriate public agency Attached , a licensed child placing agency. Attached I/We understand that this petition will not be considered until all of the required documents have been filed, all of the required investigation has occurred, and until the court is satisfied that I/we have complied with all statutory requirements. To complete this filing, the following information is provided and/or documents are attached (check all that apply): 12. Child Custody Affidavit is attached. 13. DHHS Certificate of Adoption (Form VS-9) to apply for an amended birth record with the Office of Data, Research and Vital Statistics is attached. 14. A statement of Confidential Information is attached, providing background information regarding the Petitioner(s). 15. Petitioner(s) acknowledge(s) that, upon the filing of this petition, the court is required to request a background check of the petitioner(s) and an investigation of the conditions and antecedents of the child to determine whether the child is a proper subject for adoption and whether the proposed home is suitable for the child; that the department or agency shall submit the report to the court. The petitioner(s) acknowledge(s) that the court may waive the adoption study, investigation and home study if one of the petitioners is a blood relative. 16. Disbursements. (CHOOSE ONE). A. A full accounting of all disbursements of anything of value made or agreed to be made by or on behalf of the petitioner(s) in connection with the adoption is attached. B. No accounting is attached because the petitioner(s) is/are a blood relative or the adoptee is an adult). 17. The Petitioner(s) has/have been informed that there is no legal obligation to provide information to the birth/legal parents and/or birth family of the adoptee. The Petitioner(s) further understand(s) that information may be shared directly or indirectly with the birth/legal parents and/or birth family at the discretion of the Petitioner(s). Based on this information and understanding, and after thoughtful consideration, (CHOOSE ONE): A. The Petitioner(s) do(es) not intend to share information with the birth/legal parents and/or birth family after the adoption, OR AD-001 07/16 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com  B. The Petitioner(s) intend(s) to share information about the adoptee with the birth/legal parent(s) and/or birth family after the adoption takes place, and a detailed explanation of what information is to be shared, under what circumstances it is to be shared, and how that information will be updated follows: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 18. I/We is/are aware of the existence of the adoption registry and the services available through the State Registrar of Vital Statistics pursuant to 22 M.R.S. � 2706-A. 19. I/We acknowledge(s) that the adoptee may inherit from the birth parents and birth parents' kin if the adoption decree so provides pursuant to Maine law and will so inherit if a petitioner is a legal parent of the adoptee. 20. I/We acknowledge(s) that if neither petitioner is a legal parent of the adoptee, and if neither birth parent of the adoptee has asked to preserve the adoptee's inheritance rights, this court may nonetheless place in the decree of adoption a special entry that will preserve the adoptee's right to inherit from either or both of the birth parents and the birth parents' kin. (A)I/We want such a special entry to be included in the decree. Here is the nature of the entry sought and the reasons why it is sought: ___________________