[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 ADULT ADOPTION WITH NAME CHANGE Petition of _____________________ under § 2701 of the Adoption Act: 1. Petitioner(s) desire(s) to adopt _ ______________ as one of (h is/her/their) heirs and hereby declare(s) that ( he/she/they) will perform all t he duties of parent(s) to him/her. The facts as to the Petitioner(s), the adopting parent(s), are as follows: Adopting Father: 1) [Name] 2) [Residence] 3) [Marital Status] 4) [Age] 5) [Occupation] 6) [Religious Affiliation] 7) [Racial background] 8) [Relationship to adoptee by blood or marriage, if any.] b. Adopting Mother: (same as (1) through (8) above) 2. a. 3. [Adoptee's full name, and length of time he/she has resided with Petitioners.] 4. Name to be assumed by the adoptee after adoption. ____________________ _____________________ _____________________ Given Middle Surname 5. Provide the following information 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.] American LegalNet, Inc. www.FormsWorkFlow.com 6. [State whether medical history information was obtained, and if not, explain why not.] 7. Adoptee has complied with requirements compliance with 54 Pa.C.S.A. §702.] of 54 Pa.C.S.A. §702. [Attach proof of 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. All consents required by § 271 1 are attached as exhibits or are not required. (State why not required). 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, and that he/she shall assume the name of _______________________. [Signature] Petitioner's Name] [Type [Type [Signature] Petitioner's Name] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION ______________________ (and _________________ _______) verify that we are the Petitioners named in t he foregoing petition an d that the facts set forth therein are true and correct, to the be st of my/our knowledge, information and belief. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. [Signature] [Type Name] [Signature] [Type Name] American LegalNet, Inc. www.FormsWorkFlow.com