IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY IN THE MATTER OF THE ADOPTION CASE NO.: OF: PETITION TO RECOGNIZE FOREIGN DECREE OF ADOPTION [R.C. 3107.18; Local Rule 75.4 (D)] The Petitioner (s) is/are the adoptive parent(s) of a minor child pursuant to a foreign decree or certificate of adoption and state that: PETITIONER(S) Petitioner’s Full Name: Petitioner’s Full Name: Residence: Duration of Residence: Marital Status: Date and Place of Marriage: ADOPTED CHILD Name of Child before Adoption: Name of Child after Adoption: Date and Place of Birth: ATTACHED IS A CERTIFIED COPY OF THE CHILD’S BIRTH CERTIFICATE, AND IF NOT IN ENGLISH, ALSO ATTACHED IS A TRANSLATION CERTIFIED AS TO ITS ACCURACY BY THE TRANSLATOR. A Foreign Decree or Certificate of Adoption was issued in compliance with the laws of: Name of Country Name of Court Date of Foreign Decree Case Number [NOTE: Check applicable boxes, complete applicable blanks and attach supporting documentation]. Form 75.4(D) M.C.-a Revised 09-05-01 American LegalNet, Inc. www.FormsWorkflow.com ATTACHED IS A CERTIFIED COPY OF THE FOREIGN DECREE OR CERTIFICATE OF ADOPTION WHICH HAS BEEN VERIFIED AND APPROVED BY THE IMMIGRATION AND NATURALIZATION SERVICE OF THE UNITED STATES, AND IF NOT IN ENGLISH, ALSO ATTACHED IS A TRANSLATION CERTIFIED AS TO ITS ACCURACY BY THE TRANSLATOR. Attached is a fully completed Ohio Department of Health, Division of Vital Statistics, Certificate of Adoption Form HEA 2757. The Petitioner(s) state that giving effect to the Foreign Decree or Certificate of Adoption would not violate the public policy of the State of Ohio and respectfully pray for the following Order(s). A Final or Interlocutory Order of Adoption An Order that the child’s name shall be changed to: An Order to the Department of Health to issue a foreign birth record for the adopted person under R.C. 3705.12(A)(4). Attorney for Petitioner(s) Petitioner Typed or Printed Name Typed or Printed Name Full Address (No P. O. Boxes) Full Address (No P. O. Boxes) Phone Number (Include area code) Phone Number (Include area code) Attorney Registration Number Form 75.4(D) M.C.-a Revised 09-05-01 American LegalNet, Inc. www.FormsWorkflow.com