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Report Of Intention To Adopt Form. This is a Pennsylvania form and can be use in Westmoreland Local County.
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Tags: Report Of Intention To Adopt, Pennsylvania Local County, Westmoreland
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:
REPORT OF INTENTION TO ADOPT
(23 Pa.C.S.A. § 2531)
TO THE HONORABLE, THE JUDGES OF SAID COURT:
The report of
the proposed adoptive parents, respectfully represents:
1.
That the proposed adoptive parents,
, are residents of
County, and their address is
2.
Their religious affiliation is
3.
The proposed adoptive parents have possession or physical care of
.
.
, a minor child, for the purpose and
with the intention of adopting such child.
4.
The child proposed to be adopted is:
Sex: Male (
) Female (
)
Born at:
Age:
Religious Affiliation:
5.
Born on :
Race:
The name and address of the Intermediary (if any) from which the proposed adoptive parents received the child
is:
Name
Address
6.
If the child was not received through an Intermediary:
The birth father of the child proposed to be adopted is:
Name
Address
Religious Affiliation
Rev. 12/26/06
1
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The birth mother of the child proposed to be adopted is:
Name
Address
Religious Affiliation
7.
An itemized accounting of all monies and consideration paid or to be paid to the Intermediary is as follows:
8.
The parent(s) whose parental rights are to be terminated (have) (have not) received counseling with respect to
the termination and the alternatives thereto. If counseling was received, it was provided on the following dates:
and the name and address of the counselor or agency which provided the counseling is:
Name
Address
9.
The date and circumstances surrounding the proposed adoptive parents receiving or retaining custody or physical
care of the child proposed to be adopted are:
10.
The date on which the pre-placement investigation was concluded is
11.
.
A copy of the pre-placement report is attached hereto.
I ACKNOWLEDGE THAT I HAVE BEEN ADVISED OR KNOW AND UNDERSTAND THAT THE BIRTH
FATHER OR PUTATIVE FATHER MAY REVOKE THE CONSENT TO THE ADOPTION OF THIS CHILD WITHIN 30
DAYS AFTER THE LATER OF THE BIRTH OF THE CHILD OR THE DATE HE HAS EXECUTED THE CONSENT TO AN
ADOPTION AND THAT THE BIRTH MOTHER MAY REVOKE THE CONSENT TO AN ADOPTION OF THIS CHILD
WITHIN 30 DAYS AFTER THE DATE SHE HAS EXECUTED THE CONSENT.
Date: ________________________________
_____________________________________________
_____________________________________________
Adoptive Parents
Rev. 12/26/06
2
American LegalNet, Inc.
www.FormsWorkflow.com
