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 FOR VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS PRELIMINARY ORDER (23 Pa.C.S.A. §2501 and §2502) 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 of the hearing shall be given to the petitioner and a copy of the notice as specifically set forth in 23 Pa.C.S.A. § 2503(b) shall be served upon the parent(s) or guardian of the petitioner who has not reached 18 years of age. If only one birth parent is the petitioner, such notice shall be given upon the other parent. If the petition seeks to terminate parental rights of putative father pursuant to 23 Pa.C.S.A. § 2503(b)(3), (d), such notice as specifically set forth therein shall be provided to putative father. Method of providing 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