[Attorney Caption: name, address, zip code, telephone #, ID #] IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ PETITION FOR ADOPTION Petition of _____________________ under § 2701 of the Adoption Act: Petitioner(s) desire(s) to adopt a child known to (him/her/them) as _______________ as one of (his/her/their) heirs and hereby dec lare(s) that (he/she/they) will perform all the duties of parent(s) to him/her. 1. The facts as to the Petitioner(s), the adopting parent(s), are as follows: a) Adopting Father: 1) [Name] 2) [Residenc e] 3) [Marital Status] 4) [Age] 5) [Occupation] 6) [Relig ious Affiliation] 7) [Racial background] 8) [Relationship to adoptee by blood or marriage, if any.] b) Adopting Mother: 1) (same as (1) through (8) above) 2. Dates of filing of reports, as applicable. a) [Report of Intention to Adopt:] ­ 23 Pa. C.S.A. §2531 b)[Report of Intermediary:] ­ 23 Pa. C.S.A. §2533 c) [Pre-placement Report:] ­ 23 Pa. C.S.A. §2530 d) [Home Study Report:] ­ 23 Pa. C.S.A. §2530 3. [Name and address of intermediary, if any.] 4. [Child's full name, and length of time he/she has resided with Petitioners.] 5. [If no intermediary, or if adoptee is over 18 yrs old, provide the following infor mation as to the adoptee:] a) [Sex] b) [Racial background] c) [Age and birth date] d) [Birthplace] e) [Place of residence since birth] f) [Religious affiliation] g) [A full statement of the value of all property owned or possessed by the child, if any.] h) [No provision of any act regulating the interstate placement of children has been violated.] American LegalNet, Inc. www.FormsWorkFlow.com i) [State whether medical history in formation was obtained, and if not, explain why not.] 6. Name to be assumed by the adoptee after adoption. ____________________ _____________________ _____________________ Given Middle Surname 7. All consents required by § 271 1 are attached as exhibits or are not required. (State why not required). 8. It is the desire of the Petitioner(s) t hat the relations hip of parent and child be established between the Petitioner(s) and the adoptee. 9. If no birth certifi cate or certification of registrati on of birth can be obtained, a statement of the reas on therefore and an alle gation of the efforts made to obtain the certificate with a request that the court establish a date and plac e of birth at the adoption hearing on the basis of the evidence presented. 10. State how parental rights were or will be terminated. Attach copy of decree(s). [If parental rights have not been terminated and no report of intermediary is filed, provide the following information:] a) Birth Mother: 1) [Name] 2) [Residence or last known address] 3) [Racial background] 4) [Age] 5) [Marital status at time of birth of child] 6) [Marital status during one year prior to birth of child] 7) [Religious affiliation] b) Birth Father: (same as (1) through (7) above) WHEREFORE, Petitioner(s) pray your Honorable Court to decree that the person proposed to be adopted shall have all the rights of a child and heir of Petitioner(s) and be subject to the duties of such child, an d that he/she shall assume the name of _______________________. [Type [Signature] Petitioner's Name] [Type [Signature] Petitioner's Name] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION ______________________ and _ _______________________ verify that we are the Petitioners named in the fo regoing petition and that the facts set forth therein are true and correct, to the best of our knowle dge, information and belief. We understand that false s tatements herein are made subj ect to the penalti es of 18 Pa. C. S. § 4904 relating to unsworn falsification to authorities. [Signature] [Type Name] [Signature] [Type Name] American LegalNet, Inc. www.FormsWorkFlow.com