IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF (Adoptee's name as on birth certificate) : : : : : No: OF ATTORNEY: PRELIMINARY ORDER FOR ADOPTION PETITION AND NOW this ___________ day of ________________________________, 20______ it is ORDERED AND DECREED that an evidentiary hearing on the Adoption Petition for the adoption of the above captioned ADOPTEE is set in Courtroom No. ______ for the _________ day of ________________________, 20____, at _________________ o'clock _____. M. Notice shall be provided as required by 23 Pa.C.S.A. � 2721. Unless excused by the court, the adopting parent(s), ADOPTEE and the intermediary are required to appear at the evidentiary hearing. [23 Pa.C.S.A. � 2723] All reports shall be timely filed and in no case later than 10 days before the evidentiary hearing to allow the court time to review. FURTHER, in accordance with Pa.O.C.R. No. 4.6(b), the Clerk of the Orphans' Court is DIRECTED to note in the docket that the individual(s) listed below have been given notice of this Order. BY THE COURT: _______________________________ ATTEST: ____________________________________________ cc Rev. 04/19/17 1 American LegalNet, Inc. www.FormsWorkFlow.com IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF (Adoptee's name as on birth certificate) : : : : : No: OF ATTORNEY: ADOPTION PETITION (23 Pa.C.S.A. � 2701) TO THE HONORABLE, THE JUDGE OF SAID COURT: The Petition of 1. ADOPTEE: a) Pre-adoptive name as appears on birth certificate: . [Names of Adopting Parent(s) and Consenting Birth Parent] b) Post-adoptive name: c) d) e) f) g) h) Age: Date of birth: Birthplace: Sex: Male ( Present address: Religious affiliation: (1) (2) Pre-adoption: Post-adoption: ) Female ( ) i) j) Racial background: Date and place of initial placement with adopting parent(s): Rev. 04/19/17 2 American LegalNet, Inc. www.FormsWorkFlow.com (k) Length of residence with adopting parent(s): l) m) If ADOPTEE is over 12 years of age, is the ADOPTEE's written consent attached? Yes Has ADOPTEE's birth certificate or certification of registration of birth been made a part of the record in these proceedings? [See 23 Pa.C.S.A. � 2701(9) Yes (1) If no birth certificate or certification of registration of birth can be obtained, a statement of the reasons therefor and an allegation of the effort made to obtain the certificate must be presented to the Court with a request that the Court establish a date and place of birth at the adoption hearing on the basis of the evidence presented [See 23 Pa.C.S.A. � 2701(9)]. (A) To expedite the adoption hearing and give the Court an opportunity for review, this request and relevant information shall be made a part of the record in the form of a written petition. This written petition shall be filed and a certified copy presented to the Court at least ten days before the adoption hearing. The request and factual averments shall also be presented as evidence at the adoption hearing. n) List assets possessed or owned by ADOPTEE and the value of these assets: o) Marital status of ADOPTEE: Unmarried (1) If married, state date of marriage and spouse's name, age and address: 2. ADOPTING MOTHER: (A consenting birth mother in a stepfather adoption is not considered an adopting mother. If this adoption involves a consenting birth mother in a stepfather adoption, do not complete this part of the petition.) a) b) c) d) e) Name: Maiden name: Age and date of birth: Birthplace: Present address: Rev. 04/19/17 3 American LegalNet, Inc. www.FormsWorkFlow.com (1) How long have you lived at this present address? (2) List residences during the past five years: f) Present marital status: Married If married, state: (1) (2) (3) Date: Place: Name of spouse: g) Name(s) and age(s) of person(s) who presently live in your household: h) i) j) Religious affiliation: Racial background: State your employment and approximate annual income: k) Are you related to ADOPTEE? Yes (1) If yes, state relationship: l) Have you ever been convicted of a misdemeanor or a felony? No (1) If yes, list crime, date and place of conviction: m) Do you have any communicable or contagious disease? No (1) If yes, state what it is: 3. ADOPTING FATHER: (A consenting birth father in a stepmother adoption is not considered an adopting father. If this adoption involves a consenting birth father in a stepmother adoption, do not complete this part of the petition.) a) b) c) Name: Age and date of birth: Birthplace: Rev. 04/19/17 4 American LegalNet, Inc. www.FormsWorkFlow.com d) Present address: (1) How long have you lived at this present address? (2) List residences during the past five years: e) Present marital status: Married If married, state: (1) (2) (3) Date: Place: Name of spouse: f) Name(s) and age(s) of person(s) who presently live in your household: g) State your employment and approximate annual income: h) i) j) Religious affiliation: Racial background: Are you related to ADOPTEE? Yes (1) If yes, state relationship: k) Have you ever been convicted of a misdemeanor or a felony? No (1) If yes, list crime, date and place of conviction: l) Do you have any communicable or contagious disease? No (1) If yes, state what it is: 4. Name, address and phone number of attorney representing petitioner(s): 5. Name, address and phone number of attorney or guardian ad litem who is or has represented ADOPTEE: Rev. 04/19/17 5 American LegalNet, Inc. www.FormsWorkFlow.com 6. If ADOPTEE's birth parent'(s) parental rights was/were terminated, state name(s), date(s), place(s) and manner of terminating the parental rights: 7. If Report of Intention to Adopt is required, state date of filing: 8. Name, address of Intermediary, if any: a) Filing date of Intermediary Report: b) Circumstance of placement: c) d) Did Intermediary make an interim placement pursuant to 23 Pa.C.S.A. � 2530(c)? Yes Was a favorable home study completed by a local public child-care agency, an adoption agency or a court designated licensed social worker prior to said placement? Yes e) If the home study and pre-placement reports were completed, have they been filed? Yes (1) If yes, list filing date: (2) If no, explain: f) Have the Pennsylvania State Police and child abuse clearance been filed as required by 23 Pa.C.S.A. � 6344(b)(2) and (d)? Yes (1) If no, explain why: g) Have the adopting parent(s) received the medical history information