THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: In the adoption of Case Number: (if known) PETITION FOR ADOPTION (RSA 170-B) A CERTIFIED COPY (LONG FORM) OF THE CHILD'S BIRTH CERTIFICATE AND ALL REQUIRED SURRENDERS AND ASSENTS MUST BE FILED WITH THIS PETITION. 1. Petitioner Name Date of Birth Petitioner Name Date of Birth Mailing Address Telephone Residence How long has petitioner(s) been resident(s) of this city/town? 2. Attorney Name Telephone Mailing Address 3. Marital status of petitioner(s): Bar ID # Married Civil Union Single Other If married or civil union, date and place of ceremony 4. Petitioner(s) relationship to child. Relative Foster Parent 5. Unrelated __ Date child was placed in the home of the petitioner(s) Person or agency which placed child in the home 6. Petitioner(s) were granted custody of the child on by the Court. 7. Is child an American Indian child as defined by the Indian Child Welfare Act? Yes No If yes, name and address of tribe Is tribe recognized by the federal government as eligible for federal services or certain Alaskan Yes No native corporations as defined in 43 U.S.C. §1602(c)? 8. Child Birth Name Date of Birth Place of Birth Residence Address NHJB-2185-FP (10/01/2009) (formerly AOC-082-003 and AOC-082-008) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: In the adoption of Case Number: PETITION FOR ADOPTION 9. Telephone Birth Mother Name Mailing address 10. Birth Father Name Telephone Mailing address 11. Are there any pending guardianship, juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimization, custody or other proceedings affecting this child or the proposed adoptive parents of this child? Yes No If yes, attach a separate sheet identifying and explaining each. The petitioners declare that they have the facilities and resources suitable to provide for the nurture and care of the minor adoptee, and that it is the desire of the petitioners to establish the relationship of parent and child with the adoptee. Therefore, the petitioners ask that this adoption be decreed and that the name of the child be changed to Date Petitioner Signature (Must be signed in presence of notarial officer.) Date Petitioner Signature (Must be signed in presence of notarial officer.) State of , County of This instrument was acknowledged before me on by Date My Commission Expires Affix Seal, if any NHJB-2185-FP (10/01/2009) (formerly AOC-082-003 and AOC-082-008) Petitioner(s) Signature of Notarial Officer / Title Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: In the adoption of Case Number: PETITION FOR ADOPTION ASSENTS CHILD'S ASSENT I am the child mentioned in this petition, am 14 years of age or older, and give my assent to the adoption and the change of my name as described in this form. Date Child Signature Signed in the presence of Presiding Judge ASSENT OF PETITIONER’S SPOUSE WHO IS PARENT OF ADOPTEE I am the spouse of the petitioner and parent of the adoptee, and will maintain all those parental rights along with the petitioner. I give my assent to the petitioner’s adoption of the child named in this petition and to the change of the child’s name as described in this petition. Date Parent Signature ASSENT OF PETITIONER’S SPOUSE TO ADOPTION OF ADULT I am the spouse of the petitioner, and assent to the petitioner’s adoption of the adult child named in this petition. Date Spouse Signature ASSENT OF ADOPTEE’S SPOUSE I am the spouse of the adoptee, and I assent to this adoption. Date Spouse Signature DECREE Petition for adoption is granted. Petition for adoption is granted on an interlocutory basis. (See separate Interlocutory Decree of Adoption.) Date NHJB-2185-FP (10/01/2009) (formerly AOC-082-003 and AOC-082-008) Judge Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com