[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 TO CONFIRM CONSENT TO ADOPTION Petition of ____________________________ under � 2504 of the Adoption Act: 1. [Petitioner's name, address, and relationship to child. Petitioner must be intermediary or, in the case of no intermediary, Petitioner may be proposed adoptive parent.] 2. [Child's name, address, age, date and place of birth, racial background, sex, and religious affiliation.] 3. The consent required by � 2711 was executed on ____________________________ [Attatched as Exhibit ______]. 4. [FOR BIRTH FATHER: A period of not less than thirty (30) days has elapsed since either the birth of the child or the execution of Birth Father's consent, whichever occurs later;] [FOR BIRTH MOTHER: A period of not less than thirty (30) days has elapsed since the execution of Birth Mother's consent.] 5. The person who executed the consent has failed to file or proceed with the petition for voluntary relinquishment of parental rights. WHEREFORE, the Petitioner prays your Honorable Court to hold a private hearing for the purpose of confirming the intention of the parent to relinquish voluntarily his/her parental rights as evidenced by the consent to the adoption, and further pray for American LegalNet, Inc. www.FormsWorkFlow.com a decree terminating the rights of the parent pursuant to � 2504, awarding custody of the child to [agency] or [individual(s)] and authorizing adoption of the child without further consent or notice to the parent. (Signature) (Type Petitioner's Name) DATE:______________________ American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, ____________________, verify that I am the Petitioner named in the foregoing Petition and that the facts set 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