PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE IN THE MATTER OF THE ADOPTION OF ___________________________________________ (Name after adoption) CASE NO. ________________________ 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 ____________________________________________________. PETITIONER The petitioner states the following: Full Name: _________________________________________________________ Age ___________________ Full Name: _________________________________________________________ Age ___________________ Place of Residence: _________________________________________________________________________ Street Address _________________________________________________________________________________________ _________________________________________________________________________________________ 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 resource 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: _____________________________________ Date of Birth: ___________________________ Property and Value: ______________________ 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 ___________________________________ ___________________________________________________________________________________________. 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 American LegalNet, Inc. www.FormsWorkFlow.com Amended: March 1, 2017 Discard all previous versions of this form CASE NO. ______________________ A Preliminary Estimate Accounting (Form 18.9), if required, is filed with this petition. 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 Name: ___________________________ Relationship: ___________________ Age, if minor _________ Address: _________________________________________________________ Consent filed Name: ___________________________ Relationship: ___________________ Age, if minor _________ Address: ________________________________________________________ Consent filed _____________________________________________________________, the agency has permanent custody of the minor filed under, ________________________, ___________ Consent filed PERSONS WHOSE CONSENT TO THE ADOPTION IS NOT REQUIRED No person has timely registered pursuant to R.C. 3107.062 as a putative father of the minor. Attached is Ohio Department of Jobs & Family Services Form 1697. A The consent of ________________________________________________________________________ Name Address Relationship B The consent of ________________________________________________________________________ Name Address Relationship is/are not required because: A B The parent has failed without justifiable cause to provide more than de minimis contact 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). __________________________________________________________________________________ __________________________________________________________________________________ FORM 18.0 ­ PETITION FOR ADOPTION OF MINOR PAGE 2 Amended: March 1, 2017 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ______________________ ___________________________________________ 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) Attorney Registration No. ______________________ _____________________________________________ Street Address _____________________________________________ City State Zip Code _____________________________________________ Phone Number (include area code) FORM 18.0 ­ PETITION FOR ADOPTION OF MINOR PAGE 3 Amended: March 1, 2017 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com