Commonwealth of Massachusetts The Trial Court Juvenile Court Department __________________ Division Docket No. _________________ PETITION FOR THE ADOPTION OF A MINOR (If petitioner is married, his/her spouse must join the petition.) Petitioner No. 1 ______________________________________ Petitioner No. 2 ______________________________________ (PR IN T nam e of petitioner) (PR IN T nam e of petitioner) ______________________________________ ______________________________________ (stree t address) (stree t address) ______________________________________ ______________________________________ (city or town/state/zip code) ______________________________________ ______________________________________ (city or town/state/zip code) (county) ______________________________________ (county) ______________________________________ (telephone num ber) (telephone num ber) state that they are (he/she is) desirous of adopting the following child: 1. _______________________________________________________________________________ (child’s nam e) Date of Birth ____________________________ ______________________________________ (n am e of m other or parent no. 1) ______________________________________ (stree t address) ______________________________________ ______________________________________ (city or town/state/zip code) Place of Birth ___________________________ ______________________________________ (nam e of father or parent no. 2) ______________________________________ (stree t address) ______________________________________ ______________________________________ (city or town/state/zip code) 2. The petitioner(s) is (are) of sufficient ability to rear the child, and to provide suitable support and education for the child; and 3. G G G G G the child has resided for at least six months in the home of the petitioner(s) the child was the subject of a proceeding pursuant to M.G.L. c. 210, §3 or pursuant to M.G.l. c. 119, § 26 wherein the Court dispensed with the need for consent or notice to the parent(s) on a petition for adoption. the child was the subject of a surrender which was executed pursuant to M.G.L. c. 210, §2. At the time of her surrender, the mother was _____ years old. At the time of his surrender, the father was _____ years old. the child is a blood relative or stepchild of the petitioner(s). the child is the care and custody of the petitioner. WHEREFORE, they (he/she) request(s) that the Court, grant them, him/her leave to adopt said child; and (if applicable) G waive the residence requirement for good cause: (explain) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ G decree that said child’s name be changed to that of _______________________________. Date ______________________________ ________________________________________ Signature of First Petitioner ________________________________________ Signature of Spouse/Second Petitioner JV-AP-1 (06/07) American LegalNet, Inc. www.FormsWorkFlow.com This petition is sponsored, recommended and approved by ________________________________________ a charitable corporation organized under the laws of the Commonwealth of Massachusetts for the purpose of engaging in the care of children and principally so engaged. CHILD’S CONSENT I ______________________________, being above the age of twelve years hereby consent to this adoption (P R IN T n am e of child) as requested above. Date:__________________________ Signature: ______________________________________ NOTARIZATION The above named child _________________________ made an oath before me on_____________________ (nam e of child) (date) that this consent is his/her free act and deed. Date:__________________________ Signature: ______________________________________ Print Name:______________________________ My Commission Expires:___________________________ AFFIDAVIT OF PETITIONER(S) FOR ADOPTION Parent No. 1/Mother ______________________________________ Parent No. 2/Father ______________________________________ (P R IN T nam e of petitioner, including m aiden nam e if applicable) (PR IN T nam e of petitioner) ______________________________________ ______________________________________ (stree t address) (stree t ad dress) ______________________________________ ______________________________________ ______________________________________ ______________________________________ (city o r to wn /sta te /zip co d e) (city or town/state/zip code) ______________________________________ ______________________________________ (telephone num ber) ______________________________________ ______________________________________ (d a te of b irth ) (date of birth) _ _ __ _ __ ___ _ __ _ __ _ __ _ __ _ _____________________________________ (p lace of birth: city/town, state, co unty, country) _________________________________________________ _ __ _ __ _ __ _ _ (p lace of birth: city/town, state, co unty, country) _ _ __ _ __ ___ _ __ _ __ _ __ _ __ _ _____________________________________ (o ccu p atio n a t th e tim e of a doption) _________________________________________________ _ __ _ __ _ __ _ _ (occupation at the tim e of the adoption) I (We) hereby request that a certificate of this adoption be sent to the city or town clerk of the place of the child, and that the clerk of the records amend the birth certificate of the child to reflect this adoption. ______________________________________ _________________________________________ SIGNATURE OF PARENT NO. 1/MOTHER SIGNATURE OF PARENT NO 2/FATHER NOTARIZATION The above signed made oath before me on ____________________________________ that this affidavit is her/his free act and deed. Notary Public__________________________ Print Name____________________________ My Commission Expires _________________ The above signed made oath before me on ______________________________ that this affidavit is his/her free act and deed. Notary Public_________________________ Print Name___________________________ My Commission Expires ________________ American LegalNet, Inc. www.FormsWorkFlow.com