PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF THE ADOPTION OF ____________________________________________ (Name after Adoption) CASE NUMBER ______________________________________ PETITION FOR ADOPTION OF MINOR CHILD [R.C. 3107.05] The undersigned petitions to adopt __________________________________________________, a minor, and to change the name of the minor to _______________________________________ . The petitioner states the following: PETITIONER Full Name: ______________________________________________________________ Age __________ Full Name: ______________________________________________________________ Age __________ Place of Residence _____________________________________________________________________ Street Address ______________________________________________________________________________________ City or Village or Township if unincorporated area ___________________________________________________________________ Post Office State Zip Code ________________ Duration of Residence Marital Status: _____________________ Date and Place of Marriage: _____________________________ Relationship of Minor to Petitioner: __________________________________________________________ The petitioner has facilities and resources suitable to provide for the nurture and care of the minor and it is the desire of the petitioner to establish the relationship of parent and child with the minor. MINOR TO BE ADOPTED Birth Name: __________________________________________ Date of Birth: _______________________ Place of Birth: ___________________________ Property and Value: _______________________________ 9 9 9 9 The minor is living in the home of the petitioner, and was placed therein for adoption on the _________________ day of _______________, 20 ____ by ________________________________ The minor is not living in the home of the petitioner, and resides at ___________________________ ________________________________________________________________________________. The minor will be an adopted person as defined in R.C. 3107.39; The minor will be an adopted person as defined in R.C. 3107.45; A certified copy of the birth certificate of the minor is filed with this petition or is not available due to the following: _______________________________________________________________________________ _______________________________________________________________________________________ FORM 18.0 - PETITION FOR ADOPTION OF MINOR Eff. Date: Jan 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER ________________ 9 9 9 the minor is in the permanent custody of _________________________________________ whose address is ________________________________________________________________ The guardian ad litem during the permanent custody proceedings was _________________________________________________________________________________ whose address is __________________________________________________________________ The attorney representing the minor during the permanent custody proceedings was _________________________________________________________________________________ whose address is __________________________________________________________________ PERSONS OR AGENCIES WHOSE CONSENT TO THE ADOPTION IS REQUIRED 9 9 9 Name _________________________________ Relationship:______________ Age, if minor ______ Address ___________________________________________________ 9 Consent Filed 9 Consent Filed 9 Consent Filed Name _________________________________ Relationship:______________ Age, if minor ______ Address ___________________________________________________ __________________________________________________________, the agency has permanent custody of the minor filed under ________________________, _______________ Court - County Case No. PERSONS WHOSE CONSENT TO THE ADOPTION IS NOT REQUIRED 9 A. B. AB No person has timely registered pursuant to R.C. 3107.062 as a putative father of the minor born on or after January 1, 1997. Attached is Ohio Department of Human Services Form 1697. The consent of ____________________________________________________________________ Name Address Relationship The consent of ____________________________________________________________________ Name Address Relationship is/are not required because: 99 99 99 The parent has failed without justifiable cause to provide more than the de minimis contact with the minor for a period of at least one year immediately preceding the filing of the adoption petition or placement of the minor in the home of the petitioner. The parent has failed without justifiable cause to provide for the maintenance and support of the minor as required by law or judicial decree for a period of at least one year immediately preceding the filing of the adoption petition or the placement of the minor in the home of the petitioner. State other grounds under R.C. 3107.07 (includes putative father of the minor born before January 1, 1997.) ________________________________________________________________________________ ________________________________________________________________________________ FORM 18.0 - PETITION FOR ADOPTION OF MINOR Eff. Date: Jan 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER _________________ ____________________________________ Attorney for Petitioner ____________________________________ Petitioner ____________________________________ Typed or Printed Name ____________________________________ Typed or Printed Name ____________________________________ Street Address ____________________________________ Petitioner ____________________________________ City State Zip Code ____________________________________ Typed or Printed name ____________________________________ Phone Number (Include Area Code) ____________________________________ Street Address ____________________________________ Attorney Registration Number ____________________________________ City State Zip Code ____________________________________ Phone Number (Include Area Code) FORM 18.0 - PETITION FOR ADOPTION OF MINOR Eff. Date: Jan 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com