IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ REPORT OF INTERMEDIARY The report of _______________________, intermediary, under § 2533 of the Adoption Act: 1. [Intermediary’s name and address] 2. The facts as to the child are: 1) [Name] 2) [Sex] 3) [Racial background] 4) [Age] 5) [Birth date] 6) [Birthplace] 7) [Religious affiliation] 3. [Date of the placement of the child with the adopting parent or parents. Date preplacement report was concluded and filed.] 4. The facts as to the birth mother are: 1) [Name] 2) [Residence or last known address (state which), unless rights already terminated] 3) [Racial background] 4) [Age] 5) [Marital status as of the time of the birth of the child.] 6) [Marital status during one year prior to birth of the child] 7) [Religious affiliation] 5. The facts as to the birth father are: (same as (1) through (7) above) 6. [Identify proceedings, if any, in which a decree of termination of parental rights with respect to this child has been entered.] 7. All consents required by § 2711 are attached as exhibits or are not required for the following reasons: 8. [Fees or expenses paid or to be paid to or received by the intermediary or any other person or persons to the knowledge of the intermediary by reason of the adoption placement.] 9. [A full description and statement of the value of all property owned or possessed by the child, if any.] 10. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of the child. American LegalNet, Inc. www.FormsWorkFlow.com 11. The birth certificate is attached hereto as Exhibit __________. [If no birth certificate of certification of registration of birth can be obtained, a statement of the reason why it cannot be obtained.] 12. [State whether medical history information was obtained, and if not, explain why not.] [Type [Type [Signature] name of intermediary] address of intermediary] DATE:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I, ______________________________, verify [that I am ____________________________ (title) of ______ ______________________ (name of agency) and am authorized to make this affi davit on its behalf, and] that the facts set forth in the foregoing petition are true and correct, to the best of my knowledge, information and belief. I under stand that false statements her ein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. ________________________ ____________ American LegalNet, Inc. www.FormsWorkFlow.com