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 INTERMEDIARY (23 Pa.C.S.A. § 2533) The INTERMEDIARY is required to file a report within six months after filing the Report of Intent to Adopt and shall forthwith notify adopting parents of the report and filing thereof, in writing. [An INTERMEDIARY is any person or persons or agency acting between the parent or parents and the proposed adoptive parent or parents in arranging an adoption placement. (23 Pa.C.S.A. § 2102)] 1. List name and address of INTERMEDIARY: 2. The child proposed to be adopted (ADOPTEE) is: a) b) Age, place and date of birth: c) Sex: Male ( d) Religious affiliation: e) 3. Name: Racial background: ) Female ( ) Placement of ADOPTEE with adopting parent(s): a) When: b) Where: Rev. 12/26/06 1 American LegalNet, Inc. www.FormsWorkflow.com 4. Parents of ADOPTEE: a) BIRTH MOTHER: (1) Name: (2) Age and date of birth: (3) Racial background: (4) Marital status as of the time of birth of ADOPTEE: (A) (5) b) If married, state name of husband: Marital status during one year prior to the birth of ADOPTEE: BIRTH FATHER: (1) Name: (2) Age and date of birth: (3) Racial background: (4) Marital status as of the time of birth of ADOPTEE: (A) (5) 5. If married, state name of wife: Marital status during one year prior to the birth of ADOPTEE: Identify all proceedings wherein any of ADOPTEE's parents' (or putative father's) parental rights and/or duties were terminated. [If termination occurred in a court other than the court in which the petition for adoption will be filed, attach a certified copy of the ORDER (23 Pa.C.S.A. § 2534 (3)]. 6. List residence of parent(s) of ADOPTEE if their parental rights have not been terminated: 7. Explain what consents required by 23 Pa.C.S.A. § 2711 are applicable in this Adoption. Attach the applicable consents as Exhibits to this report. (If the original consent is required as a part of another report or petition, a copy may be attached in lieu of the original.) [23 Pa.C.S.A. § 2534 (2)] Rev. 12/26/06 2 American LegalNet, Inc. www.FormsWorkflow.com 8. List an itemized accounting of monies and consideration paid or to be paid to or received by the intermediary or to or by any other person or persons to the knowledge of the Intermediary by reason of the adoption placement: 9. List full description and statement of value of all property owned or possessed by the ADOPTEE: 10. Has any provision of any statute regulating the interstate placement of children been violated with respect to the placement of the child? 11. Attach a birth certificate or certification of registration of birth. [23 Pa. C.S.A. § 2534 (1)] If no birth certificate or certification of registration of birth can be obtained, state why. [See 23 Pa.C.S.A. § 2701 (9)] 12. Has the attending physician delivered the medical history information to the intermediary or has the physician delivered the medical history information directly to the adopting parents? (See 23 Pa.C.S.A. § 2102 and § 2909) a) If not delivered, state why? b) If it was delivered, was the information edited to remove identifying information about ADOPTEE's birth family? ________________________________________ Intermediary Rev. 12/26/06 3 American LegalNet, Inc. www.FormsWorkflow.com COMMONWEALTH OF PENNSYLVANIA : : : COUNTY OF WESTMORELAND ss The above named INTERMEDIARY, being duly sworn according to law deposes and says that the facts set forth in the above Intermediary Report are true and correct to the best of his/her knowledge, information and belief. ________________________________________ [Signature of Intermediary] Sworn to and subscribed before me this ____________ day _________________________, 20________ ____________________________________ (Signature of Notary) (SEAL OF NOTARY) Rev. 12/26/06 4 American LegalNet, Inc. www.FormsWorkflow.com (Alternative Method for Verification) I the above named Intermediary do verify that the statements contained in the Intermediary's Report are true and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsifications to authorities. (The maximum penalty for such violation is a period of incarceration up to two years and a $5,000 fine.) Date _______________________ Rev. 12/26/06 _________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkflow.com