[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 AGENCY Petition of ________________________ under § 2501 of the Adoption Act: 1. [Petitioner(s)’ name(s), address(es), age(s), racial background(s) and religious affiliation(s).] 2. [Any non-petitioning parent’s name, last known address, age, racial backgr ound and religious affiliation.] 3. a.) b.) c.) [Marital status of mother as of the time of child’s birth.] [Marital status of mother one year prior to child’s birth.] [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. [Name and address of agency having care of child.] 6. [Date when child was placed with Agency] 7. [If child was born out of wedlock, whether mother and father intent to marry] 8. [Reasons for seeking relinquishment] 9. Petitioners understand this petition, ha ve cons idered the alternatives and execute this petition v oluntarily t o promot e what they believe to be in their and the child’s best interests. WHEREFORE, Petitioners pray your H onorable Co urt for a fi nding of voluntary relinquishment and for a Decree of Termination directing the transfer of custody and o f the rights and duties of parents wit h respect to their child to the aforesaid agency, and authorizing it to cons ent to t he adoption of the ch ild without further consent of or notice to Petitioners. _____________[ Signature]____________________ [Type Petitioner’s Name] American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, _______________________ verify that I am the Peti tioner 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