IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ PETITION TO CHANGE BIRTH RECORD � GESTATIONAL CARRIER NOW COME, Petitioners __________ ________ and ______________ ______. by their attorney, ______ _______________, Esquire, and make the following averments in support of this Petition reques ting that they be decla red the legal parents of a child, ____________________________, born by a gestational carrier, and that the birth certificate shall so reflect such parentage: 1. Petitioners are adult individuals, and husband and wife, residing at ____________________________ _______________________________________, [CITY/BOROUGH/TOWNSHIP], Chester County, Pennsylvania. 2. Because of Petitioner _____ _________________________'s inability to bear childr en, an in v itro fertiliza tion proced ure was pe rformed, whereby ova retrieve d from an anonymou s ovum d onor were fertilized with the sperm o f Petitione r _____________________________. 3. The afore mentioned in vitro f ertilization procedur e was p erformed at vision of [PHYSICIAN' S [NAME AND ADDRESS OF FACILITY], under the super NAME], and resulted in viable human embryos which were cyropreserved. 4. On [DATE], one of the aforementi oned em bryos was transferred by the aforementioned [NAME OF PHYSICIAN] to the uterus of [GEST ATIONAL CARRIER'S NAME]. American LegalNet, Inc. www.FormsWorkFlow.com 5. The said [GESTATIONAL CARRIER' S NAME] is an adult individual (D/O/B _________________), who resides at [STREET, MUNICIPALITY, STATE]. 6. The aforementioned ova re trieval, in vitro fertiliz ation and embryo transfer ITY NAME & ADDRESS], by or under the procedures were all performed at [FACIL supervision of [PHYSICIAN'S NAME]. 7. The aforementioned embryo transfer resulted in a viable pregnancy in the uterus of the said [GESTATIONAL CARRI ER'S NAME], with a child, [CHI LD'S NAME] born thereon on [CHILD'S D/O/B], at [FACILITY NAME & ADDRESS]. 8. The aforementioned child [CHILD 'S NAME] to whom [GESTATIONAL 'S D/O/B], was conceived through the CARRIER'S NAM] gave birth on [CHILD aforementioned in vit ro fertilization proc edure and was not con ceived wit h [FEMAL E PETITIONER'S NAM E]'s own ova. Attached Affidavit of [PHYSICIAN'S NAME] confi [GESTATIONAL CARRIER] on [DATE OF PETITIONER'S NAME]'s sperm and anony notarized copies of the hereto and marked "Exhib it A" are: 1) rming that the embryo transferred to PROCEDURE] wa s cr eated with [MALE mous donor ova; and 2) verified and Genetica DNA parentage test results, showing a 99.97% the genetic father of the child and excluding probability that Petitioner is [GESTATIONAL CARRIER] as a genetic parent. 9. Prior to the aforementioned embr yo transfer, [GESTATIONAL CARRIER] agreed to act as a gestational carrier of the aforementioned embryos for Petitioners and expressed her intent, in a si gned writing, that Petitioners shall have exclusiv e custody and all par ental rights and duties with respect to any child resulting therefrom, and she has continued to express that intent. American LegalNet, Inc. www.FormsWorkFlow.com 10. Prior to the aforementioned embr yo transfer, [GESTATIONAL CARRIER] agreed that she intended to not have phys ical or lega l custody or any parental rights with respect to any such child, and she has continued to express that intent. 11. Prior to the aforementioned transf er, Petitioner [MALE PETITIONER' S NAME] expressed his intent that Petition parental rights and duties with respect to continued to express that intent. 12. ers shall have exclusive custody and all any child resulting therefrom, and has Prior to the aforementioned em bryo transfer, Petitioners expres sed their intent, in a signed writing, t hat they shall have exc lusive custody and all par ental rights and duties with respect to any such child, intent. 13. Since his/her discharge from the hospi tal of birth, the said [CHILD] ha s and they have conti nued to express that been in the care of Petitioners and has c ontinuously resided with them at Petitioner's residence. 14. Attached hereto and marked "Exhibit B" is an affidavit from Petitioners verifying the aforementioned facts. 15. Attached hereto and marked "Exhibit C" is the parental acknowledgement of [FEMALE PETITIONER]. 16. Attached hereto and marked "Exhibit D" is the parental acknowledgement of [FEMALE PETITIONER]'s husband, [MALE PETITIONER]. 17. Attached hereto and marked "Exhibit E" is a stipulation executed b the Pe y ________________________, Esquire, Senior Counsel of nnsylvania American LegalNet, Inc. www.FormsWorkFlow.com Department of Health, and the undersigned, agreeing to the entry of the decree which is attached hereto. WHEREFORE, Petitioners pray this Ho norable Court, based upon this Petition and the attached Exhibits, that a Decree be entered determining that Petitioners _______________________ and __________________________ are the legal parents of the aforementioned child _________________ __________, born on [ D/O/B] at [PLACE OF BIRTH], and that the birth certif icate to be issued by the Pennsylvania Department of Health reflect the parentage of Petitioners __________________________ and _________________________ to said child. Respectfully submitted, ______________________________________ Attorney for Petitioners American LegalNet, Inc. www.FormsWorkFlow.com