IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ PETITION FOR ADOPTION BY UNMARRIED COUPLE CONSENT OF PARENT TO ADOPTION 1. [Name, age and marital status of consenting parent.] 2. [Name, sex and birth date of child.] 3. [Name of other parent of child.] I hereby voluntarily and unconditionally consent to the adoption of my above- named child by my partner, _______________________________. By signing this cons ent, I do not indica parental rights to this child. I understand that my partner, _________ _______________________, desires to adopt such child as one of his/her heirs and to perform all the duties of parent to him/her. I understand that I may not revok e this consent after a decree of adoption of this child is entered. I have read and understand the above and I am si gning it as a free and volunt ary act. Date:_________________________ ___________________________________ [SIGNATURE] te an inten t to relinq uish a ny o f my ___________________________________ [TYPE NAME ] American LegalNet, Inc. www.FormsWorkFlow.com