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: NOTICE (Confirm Consent) TO: A petition has been filed asking the court to put an end to all rights you have to your child __________________. The court has set a hearing to consider ending your rights to your child. That hearing will be held in Courtroom # ______ on the ________ day of ________________________, 20_______ at ____________ A.M./P.M. YOU ARE WARNED THAT EVEN IF YOU FAIL TO APPEAR AT THE SCHEDULED HEARING, THE HEARING WILL GO ON WITHOUT YOU AND YOUR RIGHTS TO YOUR CHILD MAY BE ENDED BY THE COURT WITHOUT YOUR BEING PRESENT. YOU ARE ALSO NOTIFIED OF THE ACT 101 OF 2010 WHICH ALLOWS FOR AN ENFORCEABLE VOLUNTARY AGREEMENT FOR CONTINUING CONTACT OR COMMUNICATION FOLLOWING AN ADOPTION BETWEEN AN ADOPTIVE PARENT, A CHILD, A BIRTH PARENT, AND/OR A BIRTH RELATIVE OF THE CHILD, IF ALL PARTIES AGREE AND THE WRITTEN VOLUNTARY AGREEMENT IS APPROVED BY THE COURT. YOU HAVE A RIGHT TO BE REPRESENTED AT THE HEARING BY A LAWYER. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LAWYER REFERRAL SERVICE WESTMORELAND BAR ASSOCIATION P.O. BOX 565 GREENSBURG, PA 15601 (724) 834-8490 www.westbar.org (Name of Attorney) (Address) (Telephone Number) Rev. 09/15/16 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: PETITION TO CONFIRM CONSENT TO ADOPTION PRELIMINARY ORDER (23 Pa.C.S.A. � 2504) AND NOW, this _______ day of ___________________________, 20______ to Judicially resolve the attached petition, it is ORDERED AND DECREED that an evidentiary hearing is set in Courtroom No. _____ for the _________ day of _______________________, 20_____, at ______________ o'clock ____.M. At least ten days written notice, as required by 23 Pa.C.S.A. � 2503(b), shall be given to the following: (1) (2) (3) parent(s) who have consented in attached petition, parent(s) who have not consented in attached petition, to the parent(s) or guardian of consenting parent(s) who is/are under the age of 18. The parent(s) consenting in attached petition and their parent(s) or guardian if under 18 years of age and/or the putative father whose parental rights are being exposed to termination shall also be advised in said notice that their parental rights may be terminated at the aforesaid hearing. Method of providing said notice shall conform to Pennsylvania Supreme Court Orphans' Court Rule Nos. 5.1 and 15.6. "Affidavit of Service" relative to all notices shall be filed at least 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: ______________________________________, J. ATTEST: _____________________________________ cc: Rev. 09/15/16 2 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: PETITION TO CONFIRM CONSENT TO ADOPTION (23 Pa.C.S.A. � 2504) CONSENT BY: "X" those that apply BIRTH MOTHER BIRTH FATHER PUTATIVE FATHER TO THE HONORABLE, THE JUDGE OF SAID COURT: The Petition of 1. ADOPTEE: a) b) c) d) e) f) g) h) i) List name as appears on birth certificate: Age: Date of birth: Birthplace: Sex: Male ( Present address: Religious affiliation: Racial background: Who has custody of ADOPTEE and since when: ) Female ( ) . [Adoptive parent(s) or Intermediary] Rev. 09/15/16 3 American LegalNet, Inc. www.FormsWorkFlow.com 2. BIRTH MOTHER: a) b) c) d) e) f) Name: Maiden name: Age and date of birth: Birthplace: Present address: Present marital status: Married If married, state: (1) (2) (3) g) Date: Place: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) If yes, name of spouse: h) If ADOPTEE was born out of wedlock, do you intend to marry the birth father? [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(7) and 15.3(a)] No i) Were you married one year prior to the birth of ADOPTEE? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) (2) If yes, name of spouse: If this marriage ended, state how and when: j) The last known address of ADOPTEE's BIRTH FATHER: k) List the names of all other husbands of BIRTH MOTHER: [PA Orphans' Court Rule 15.3(a)] l) What is your employment? m) n) Religious affiliation: Racial background: Rev. 09/15/16 4 American LegalNet, Inc. www.FormsWorkFlow.com o) Are you consenting to have your parental rights terminated? Yes (1) Is your consent to the adoption as required by 23 Pa.C.S.A. � 2504 attached to this petition? Yes 3. BIRTH FATHER: a) b) c) d) e) Name: Age and date of birth: Birthplace: Present address: Present marital status: Married If married, state: (1) (2) (3) f) Date: Place: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) If yes, name of spouse: g) If ADOPTEE was born out of wedlock, do you intend to marry the birth mother? [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(7) and 15.3(a)] No h) Were you married one year prior to the birth of ADOPTEE? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) (2) If yes, name of spouse: If this marriage ended, state how and when: i) The last known address of ADOPTEE's BIRTH MOTHER: j) What is your employment? k) l) m) Religious affiliation: Racial background: Are you consenting to have your parental rights terminated? Yes Rev. 09/15/16 5 American LegalNet, Inc. www.FormsWorkFlow.com (1) 4. Is your consent to the adoption as required by 23 Pa.C.S.A. � 2504 attached to this petition? Yes PUTATIVE FATHER: a) b) c)