IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ PETITION TO VOLUNTARILY RELINQUISH PARENTAL RIGHTS [TO AGENCY OR TO ADULTS INTENDING TO ADOPT CHILD] IMPORTANT NOTICE � PUTATIVE FATHER TO: [NAME] [ADDRESS] A petition has been filed asking the court to put an end to all rights you have to your child, ___________________________________. The court has set a hearing to consider ending your rights to your child. That hearing will be held in the Chester County Justice Center, West Chester, Pennsylvania on _____________________, 20____, at ____:____ am/pm in Courtroom No.______, before the Honorable _________________________. You are warned that your rights may also be subject to termination pursuant to �2504(d) of the Adoption Act, 23 Pa.C.S., if you fail to file either an acknowledgment of paternity or claim of paternity pursuant to 23 Pa. C.S. �5103 (relating to acknowledgment and claim of paternity) and fail to either appear at the hearing for the purpose of objecting to the termination of your rights or file a written objection to such termination with the Court prior to the hearing. You have a right to be represented at the hearing by a lawyer. You should take this paper to your lawyer at once. If you do not have a lawyer or cannot afford one, go to or telephone the office set forth below to find out whether you can get legal help. LAWYER REFERRAL SERVICE CHESTER COUNTY BAR ASSOCIATION 15 WEST GAY STREET SECOND FLOOR WEST CHESTER, PENNSYLVANIA 19380 610-429-1500 American LegalNet, Inc. www.FormsWorkFlow.com