[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 VOLUNTARILY RELINQUISH PARENTAL RIGHTS TO ADULTS INTENDING TO ADOPT CHILD Petition of _______________________________ under § 2502 of the Adoption Act: 1. [Petitioner(s)’ name(s), address(es), age( affiliation(s).] s), racial backgroun d(s) and religiou s 2. [Any non-petitioning parent ’s name, last known address, age, racial back ground and religious affiliation.] 3. (a) [Marital status of mother as of the time of child’s birth.] (b) [Marital status of mother one year prior to child’s birth.] (c) [If mother ever married: name(s) of husband(s); maiden name.] 4. [Child’s name, age, date of birth, racial background, sex and religious affiliation.] 5. [Date of filing of Report of Intention to Adopt] 6. [Date child was placed with persons having custody.] 7. [If child was born out of wedlock whether mother and father intend to marry.] 8. [Reasons for seeking relinquishment] 9. Petitioners understand this petition, have considered the alternatives and execut e this petition voluntarily to promote what they believe to be in their and the child’s best interests. WHEREFORE, Petitioner(s) pray your H onorable Court for a finding of voluntary relinquishment and for a Decree of Termination directing the tr ansfer of the custody of their child to adults intending to adopt the child, and authorizing the adoption of the child without further consent of or notice to Petitioner(s). _____________[Signature]____________________ [Type Petitioner’s Name] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, _______________________ v erify that we 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 under stand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 r elating to unsworn falsification to authorities. _____________[ Signature]____________________ American LegalNet, Inc. www.FormsWorkFlow.com