American LegalNet, Inc. www.FormsWorkFlow.com IN RE: : ADOPTION OF : : No: OF : (Adoptee222s name as on birth certificate) : ATTORNEY: (23 Pa.C.S.A. 247 2511) 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 shall be given to the parent(s) and putative father whose rights are to be terminated and to the parent(s) or guardian of a minor parent whose rights are to be terminated. A copy of the notice shall be given to the other parent. Manner of service and contents of notice shall comply with 23 Pa.C.S.A. 247 2513(b). 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 Orphans222 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: American LegalNet, Inc. www.FormsWorkFlow.com IN RE: : ADOPTION OF : : No: OF : (Adoptee222s name as on birth certificate) : ATTORNEY: (23 Pa.C.S.A. 247 2511) PARTIES WHOSE RIGHTS ARE BEING TERMINATED: "X" those that apply BIRTH MOTHER BIRTH FATHER PUTATIVE FATHER TO THE HONORABLE, THE JUDGE OF SAID COURT: The Petition of . [See 23 Pa.C.S.A. 247 2512(a) for parties who are authorized to be petitioner(s)] 1. ADOPTEE: a) List name as appears on birth certificate: b) Age: c) Date of birth: d) Birthplace: e) Sex: Male ( ) Female ( ) f) Present address: g) Religious affiliation: h) Racial background: i) Who has custody of ADOPTEE and since when: 2. BIRTH MOTHER: American LegalNet, Inc. www.FormsWorkFlow.com a) Name: b) Maiden name: c) Age and date of birth: d) Birthplace: e) Present address: f) Present marital status: Married If married, state: (1) Date: (2) Place: (3) Name of spouse: g) 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) If yes, name of spouse: (2) 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) Religious background: n) Racial background: 3. BIRTH FATHER: a) Name: American LegalNet, Inc. www.FormsWorkFlow.com b) Age and date of birth: c) Birthplace: d) Present address: e) Present marital status: Married If married, state: (1) Date: (2) Place: (3) Name of spouse: f) 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) If yes, name of spouse: (2) If this marriage ended, state how and when: i) The last known address of ADOPTEE's BIRTH MOTHER: j) What is your employment? k) Religious background: l) Racial background: 4. PUTATIVE FATHER: a) Name: b) Age and date of birth: c) Birthplace: d) Present address: e) Present marital status: Married American LegalNet, Inc. www.FormsWorkFlow.com If married, state: (1) Date: (2) Place: (3) Name of spouse: f) 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) If yes, name of spouse: (2) If this marriage ended, state how and when: i) Was PUTATIVE FATHER ever married to BIRTH MOTHER? Yes (1) If yes, state when: j) What is your employment? k) Religious background: l) Racial background: m) Explain the circumstances that created the status of PUTATIVE FATHER: n) If this petition does not identify the father of ADOPTEE, attach a certification from the Department of Health as to whether a claim of paternity has been filed pursuant to 23 Pa.C.S.A. 247 5103. [23 Pa.C.S.A. 247 2512(c)] (1) Has a claim of paternity been filed? Yes (2) 23 Pa.C.S.A. 247 2513 requires a copy of notice be given to putative father. It further states a putative father shall include one who has filed a claim of paternity as provided in 23 Pa.C.S.A. 247 5103 (relating to acknowledgements and claim of paternity) prior to the institution of proceedings. 5. State relationship of petitioner(s) to ADOPTEE: 6. If petitioner is an approved AGENCY or INSTITUTION, state complete name and address: American LegalNet, Inc. www.FormsWorkFlow.com If a consenting parent is under the age of 18 years, state name(s) and address(es) of his/her parent(s) (or guardian). 8. If parental rights are being terminated to adult(s) intending to adopt, is the identity of the proposed adoptive parent(s) known to the terminating parent(s)? Yes a) If yes, state name(s) and address(es) of proposed adoptive parent(s). b) Are proposed adoptive parents married? Yes 9. Are any of the ADOPTEE'S birth parent(s) or putative father deceased? No a) If yes, state name, relationship to ADOPTEE, date of death and attach an original death certificate as an Exhibit. 10. No Report of Intention to Adopt is required if the ADOPTEE is "the child, grandchild, stepchild, brother or sister of the whole or half blood or niece or nephew by blood, marriage or adoption" of the adopting parent(s) [23 Pa C.S.A. 2531(c)]. In all other cases, persons receiving custody for an adoption are required to file a Report of Intention to Adopt within thirty days of receiving custody or physical care [23 Pa.C.S.A. 247 2532]. Is a Report of Intention to Adopt required in this case? Yes a) If yes, when and where was the Report of Intention to Adopt filed? [Pennsylvania Supreme Court Orphans' Court Rule 15.3(a)(1)] b) If yes, when and where was physical custody of ADOPTEE placed with adoptive parent(s)? [Pennsylvania Supreme Court Orphans' Court Rule 15.3(a)(2)] c) Has the attached consent of the adult(s) accepting custody of ADOPTEE been completed and signed? [Pennsylvania Supreme Court Orphans' Court Rule 15.3(b)] Yes 11. Is birth certificate or certification of registration of birth of ADOPTEE attached as an Exhibit? [Pennsylvania Supreme Court Orphans' Court Rules 15.4(b)(1)] Yes a) If no, see 23 Pa.C.S.A. 247 2701(9) and question 1(m) in Adoption Petition form. 12. 23 Pa.C.S.A. 247 2512(b) mandates that the Petition for Involuntary Termination of Parental Rights "shall set forth specifically those grounds and facts alleged as the basis for terminating parental rights". Therefore, cite the specific subsections of 23 Pa.C.S.A. 247 2511 which establish the legal basis for the requested termination(s) and state the alleged facts which justify the requested termination(s). Has this information been attached as Appendix No. 1 to this petition? Yes American LegalNet, Inc. www.FormsWorkFlow.com 13. List the name(s) of person(s) whose parental rights may be terminated by these proceedings, who is a member of the United States armed services and thereby entitled to the benefits of the Soldiers' and Sailors' Civil Relief Act of 1940 as amended, 50 U.S.C.A 247 501 et. seq. [Pennsylvania Supreme Court Orphans' Court Rule No. 15.4(a)(7)] 14. As soon as petitioner(s) or attorney(s) has/have reason to believe these proceedings will be contested, the court must be notified IMMEDIATELY so that an attorney may be appoint