IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ REPORT OF INTENTION TO ADOPT The report of ________________________________ under §2531 of the Adoption Act: 1. The person(s) filing the Report have cust ody or physic al care of t he child for the purpose or with the intention of adopti ng the child. [The circumstances surrounding the persons receiving or reta ining custody or physical care of the child, inc luding the date upon whic h a preplacement investigation was concluded.] 2. [Child's name, sex, racial backgr ound, age, date and place of bir th and religious affiliation.] 3. [Name and address of the intermediary.] 4. [An itemized accounting of moneys and co nsideration paid or to be paid to the intermediary.] 5. [Whether the parent or parents whose pa rental rights are to be terminated have received c ounseling with respect to t he termination of their rights and the alternatives thereto. If so, the r eport shall state the dates on which the counseling was provided and the name an d address of the co unselor or agency which provided the counseling.] 6. [The name and address of the person(s) filing the report.] 7. [A copy of the preplacement report prepared pursuant to §2530 (relating to home study and preplacement report) is attached.] I acknowledge that I have been advised or know and understand that the Birth Father or Putative Father may revoke the consent to the adoption of this child within thirty (30) American LegalNet, Inc. www.FormsWorkFlow.com days after the later of the birth of the child or the date he has executed the consent to an adoption and that the Birth Mother may revoke the consent to an adoption of this child within thirty (30) days after the date she has executed the consent. ____________________________ (Signature) (Type Name & Address) _____________________________ (Signature) (Type Name & Address) American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION _________________________ and ____________________ ________, verify that the facts set forth in the foregoing report are tr ue and correct, to the best of our knowledge, information and belief. We understand that fals e statements herein are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. ________________[Signature]_____ [Type Name] ________________[Signature]_____ [Type Name] American LegalNet, Inc. www.FormsWorkFlow.com