IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ CONSENT OF ADOPTEE I, [ADOPTEE], am over twelve (12) years of age, have read the foregoing petition ad consent to my adoption by [PETITIONER]. I also agree to having my name changed to [NAME AFTER ADOPTION]. I have read and understand the above and I am signing it as a free and volunt ary act. Date Place _______________[SIGNATURE]___________ Type Name: of Execution: of Execution WITNESSES: RELATIONSHIP TO ADOPTEE: [SIGNATURE]______________ _________________ Type name: Type Address: [SIGNATURE]______________ _________________ Type name: Type Address: American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ [Signature] ______________________________ [Signature] American LegalNet, Inc. www.FormsWorkFlow.com