COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.IN THE COMMON PLEAS COURT OF ERIE COUNTY, OHIOJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)PROBATE DIVISIONIN THE MATTER OF THE*CASE NO. PLACEMENT FOR ADOPTION OF**PERMANENT SURRENDER *OF CHILD * ********************************************************************************The undersigned, , residing at Name states that is the Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .He/SheTHE PEOPLE OF THE STATE OF NEW YORK TO of born Mother/FatherChildDateat in HospitalCityCountyState states that desires to place said child for the NameGREETINGS:He/SheWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorablepurpose of adoption, and that it is in the best interest of said child as is not He/She able to care for said child in the means and manner which are in the child's best interest.The undersigned hereby agrees to permanently surrender said child and understands that by doing so, all parental rights will be terminated and will He/She now and forever be freed of all contracts, legal rights, and obligations as parent of said child. It is understood that the adoption of said child is an irrevocable act and approval of this form by is a knowing and voluntary act. Him/Her,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,NameSTATE OF OHIO SS: COUNTY OF Erie County , being first duly sworn, deposes and says that the statements contained in the foregoing permanent surrender are true, as he/she verily believes, and that filing the foregoing waiver is his/her voluntary act and deed for the uses and purposes therein mentioned.(Attorney must sign above and type name below)ERIEAttorney(s) forOffice and P.O. AddressNameTelephone No.: Facsimile No.: E-Mail Address:Sworn to before me and subscribed in my presence on this day of Mobile Tel. No.:Notary PublicAmerican LegalNet, Inc. www.USCourtForms.com