[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 ALTERNATIVE RELINQUISHMENT BY PUTATIVE FATHER Petition of _______________ _____________ under § 2504(c) of the Adoption Act: 1. [Petitioner's name, address, and relati onship to child. Petitioner must be intermediary or, in the case of no inte rmediary, Petitioner may be propos ed adoptiv e parent.] 2. [Child’s name, address, age, date and place of birth, racial background, sex, and religious affiliation.] 3. [Putative Father's name, address] 4. The putative father has failed to execute a consent to the adoption as required by 23 Pa.C.S.A. §2711 and has not filed an ackneldgment or claim of paternity pursuant to 23 Pa.C.S.A. §5103. 5. [Putative Father] has receiv ed notice of adoption proceeding and an opportunity to execute a consent on [DATE], (Documentation attached). WHEREFORE, the Petitioner pr ays your Honorable Court to issue a decree terminating the rights of the above-named putative father to § 2504(c), awarding American LegalNet, Inc. www.FormsWorkFlow.com custody of the child to [agency] or [indivi dual(s)] and authorizing adoption of the child without further consent or notice to the putative father. (Signature) DATE:______________________ (Type Petitioner’s Name) American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, ____________________, verify that I am the Petitioner named in the foregoing Petition and that the facts se t forth therein are true and correct, to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. (Signature) American LegalNet, Inc. www.FormsWorkFlow.com