P:\January 2005 Adoption Packet.doc CHECKLIST PETITION TO CHANGE BIRTH RECORD – GESTATIONAL CARRIER Documents to be attached to the Petition in the order they appear: ____ Preliminary Decree, only if all affidavits not present/someone contests ____ Final Decree ____ Petition to Change Birth Record – Gestational Carrier ____ ____ ____ ____ ____ ____ Attorney Caption Signed by Attorney for Petitioner Verified by Petitioner Petitioner(s) is/are Intended Parent(s) Petitioner(s) is/are Donor(s) Petitioner(s) is/are not Donor(s) Contents of Petition: ____ ____ ____ ____ ____ ____ Name(s) and Address(es) of Intended Parent(s) Name and Address of Gestational Carrier Name and Address of Donor, if different than Intended Parent(s) Name of Person who Performed the Assisted Conception Address of Facility where the procedure was performed Facts and circumstances surrounding the performing of the procedure and its resulting in a successful pregnancy ____ Date of birth, or expected date of birth of the child Exhibits: ____ Statement from Person/Facility performing procedure certifying facts as to the procedure ____ Certified copy of any agreement among the parties ____ Affidavit signed by the Intended Parent(s) ____ Affidavit signed by the Gestational Carrier ____ Affidavit signed by the husband of Gestational Carrier ____ Affidavit signed by the Donor(s), if different than Gestational Carrier or Intended Parents ____ Affidavit signed by spouse of Donor(s) if different than Gestational Carrier or Intended Parents ____ Stipulation executed by the PA Department of Health (or counsel) and petitioners (or counsel) that the proposed Decree is acceptable to them ____ Order to Impound Records ____ Motion to Impound Records American LegalNet, Inc. www.USCourtForms.com