Probate Court of Lake County, Ohio MARK J. BARTOLOTTA, JUDGE (Name after adoption) ADOPTION OF CASE NUMBER ______________ **INTERNATIONAL ­ PRELIMINARY ** PETITION FOR ADOPTION OF MINOR (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: Full name: Place of Residence: Street Address Post Office State City/Village/Township Zip Code County Duration of Residence Age: Age: 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: Place of birth: day of , by Date of birth: Property and value: The minor is living in the home of the petitioner, and was placed therein for adoption on the 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: A Preliminary Estimate accounting (Form 18.9), if required is filed with this petition. The minor is in the permanent custody of is American LegalNet, Inc. www.FormsWorkFlow.com whose address (Second page of Form 18.0) PERSONS OR AGENCIES WHOSE CONSENT TO THE ADOPTION IS REQUIRED minor filed under Court ­ County Case No. Name: Address: Name: Address: Relationship: Relationship: Age, if minor Consent filed Age, if minor Consent filed , the agency has permanent custody of the Consent filed PERSONS WHOSE CONSENT TO THE ADOPTION IS NOT REQUIRED A B 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 ofd Name Address Relationship is/are not required because: A B The parent has failed without justifiable cause to communicate with the minor 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. 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.) Attorney for Petitioner Typed or Printed Name Street Address City State Zip Code Petitioner Typed or Printed Name Petitioner Typed or Printed Name Street Address City State Zip Code Phone Number (include area code) Attorney Registration No. Print Reset Phone Number (include area code) American LegalNet, Inc. www.FormsWorkFlow.com