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 FINAL DECREE AND NOW, this _____ day of _____________________, 20_____, upon consideration of the within Petition and after hearing had thereon: The Court, being satisfied as to the truth of the facts set forth in the Petition, and that it is in the best interests of [NAME EXACTLY AS ON BIRTH CERTIFICATE] that the Petition be granted, it is ORDERED, ADJUDGED, and DECREED that all parental rights and duties, including the duty of support of ________[PARENT}________ in respect to ________[CHILD]_________ are terminated forever and custody of ________[CHILD]_________ is hereby awarded to [AGENCY], which is hereby authorized to give consent to the adoption of said child and adoption of said child may be decreed without further consent of or notice to the aforesaid parent(s). BY THE COURT: ______________________________________ J. American LegalNet, Inc. www.FormsWorkFlow.com