[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 INVOLUNTARY TERMINATION OF PARENTAL RIGHTS AGENCY PETITION Petition of _________________________ under § 2512 of the Adoption Act: 1. [Agency's name, address and standing] 2. [Child's name, age, date of birth, racial background, sex and religious affiliation.] 3. The facts as to the birth parents of the child are: a. Mother: 1) [Name] 2) [Address] 3) [Age] 4) [Racial background] 5) [Relig ious affiliation] 4. b. Father: 1 1) [Name] 2) [Address] 3) [Age] 4) [Racial background] 5) [Relig ious affiliation] 5. 1) 2) 3) [Marital status as of the time of the birth of the child] [Marital status during one year prior to the birth of the child] [If ever married: name(s) of husband(s); maiden name] 6. [Date child was placed in care of Petitioner.] 7. [Facts constituting grounds for termination (Identify specific subsection of § 2511(a) of Adoption Act).] 8. [State whether either parent is entitled to benefits of the Soldiers' and Sailors' Civil Relief Act of 1940, as amended (50 USCA §501 et seq.).] 9. Petitioner will assume custody of the child until such time as the child is adopted. If father not ident ified, state whe ther cla im of patern ity filed p ursuant to 23 Pa. C.S.A. §5103 (b) and explain why birth father is unknown. 1 American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, Petitioner prays your Honor able Court for a finding of involuntary termination of parental right s of _________ ____________ (and) _____________________, an d for a decree terminating all parental rights of _____________________ (and) ] in respect to ______________________, awarding custody of the c hild to Petitioner, and authorizing it to consent to the adoption of _______________________. [Name of Agency] By: [Signature] [Type Name and Title] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, _________________________, verify that I am [title] of [name of agency] , that I am aut horized to make this affidavit on its behalf, and that the facts set forth in the for egoing Petition are true and co rrect, to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of authorities. 18 Pa. C.S. § 4904 relating to unsworn falsification to [Signature] [Type Name] American LegalNet, Inc. www.FormsWorkFlow.com