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 (Voluntary Relinquishment) 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. Your presence is required at the hearing. 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 (Name of Attorney) (Address) (Telephone Number) 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 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. BY THE COURT: _______________________________________________ J. ATTEST: _________________________________ 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 FOR VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS (23 Pa.C.S.A. §2501 and §2502) RELINQUISHMENT TO: "X" the one that applies. To Agency (23 Pa.C.S.A. § 2501) To Adult(s) intending to adopt (23 Pa.C.S.A. § 2502) RELINQUISHMENT BY: "X" those that apply. BIRTH MOTHER. BIRTH FATHER. PUTATIVE FATHER. TO THE HONORABLE, THE JUDGE OF SAID COURT: The Petition of 1. . [Names of Relinquishing Parent(s)] ADOPTEE: a) List name as appears on birth certificate: b) Age: c) Date of birth: d) Birthplace: e) Sex: Male ( ) Female ( ) 3 American LegalNet, Inc. www.FormsWorkFlow.com f) g) Religious affiliation: h) Racial background: i) 2. Present address: Who has custody of ADOPTEE and since when: BIRTH MOTHER: 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) (2) Place: (3) g) Date: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) h) If yes, name of spouse: 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) j) If yes, name of spouse: If this marriage ended, state how and when: The last known address of ADOPTEE's BIRTH FATHER: 4 American LegalNet, Inc. www.FormsWorkFlow.com 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 affiliation: n) Racial background: o) Are you voluntarily relinquishing your parental rights? Yes (1) If yes, state reasons for seeking relinquishment: [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(8) and 15.3(a)] (2) Is your consent to the adoption attached? Yes (3) THE PARENT RELINQUISHING PARENTAL RIGHTS MUST PERSONALLY APPEAR IN COURT AT THE VOLUNTARY RELINQUISHMENT HEARING. [23 Pa.C.S.A. § 2503] (4) The BIRTH MOTHER has executed this petition voluntarily to promote what the BIRTH MOTHER believes to be in her best interest and the ADOPTEE's best interest. [Pennsylvania Supreme Court Orphans' Court Rules Nos. 15.2(a)(9) and 15.3(a)] 3. BIRTH FATHER: a) Name: b) Age and date of birth: c) Birthplace: d) Present address: e) Present marital status: Married If married, state: (1) (2) Place: (3) f) Date: 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: 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 affiliation: l) Racial background: m) Are you voluntarily relinquishing your parental rights? Yes (1) If yes, state reasons for seeking relinquishment: [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(8) and 15.3(a)] (2) Is your consent to the adoption attached? Yes (3) THE PARENT RELINQUISHING PARENTAL RIGHTS MUST PERSONALLY APPEAR IN COURT AT THE VOLUNTARY RELINQUISHMENT HEARING. [23 Pa.C.S.A. § 2503] (4) The BIRTH FATHER has executed this petition voluntarily to promote what the BIRTH FATHER believes to be in her best interest and the ADOPTEE's best interest. [Pennsylvania Supreme Court Orphans' Court Rules Nos. 15.2(a)(9) and 15.3(a)] 4. PUTATIVE FATHER: a) Name: b) Age and date of birth: c) Birthplace: d) Present address: e) Present marital status: Married 6 American LegalNet, Inc. www.FormsWorkFlow.com If married, state: (1) (2) Place: (3) f) Date: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) g) If yes, name of spouse: 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) i) If yes, name of spouse: If this marriage ended, state how and when: Was PUTATIVE FATHER ever married to BIRTH MOTHER? Yes (1) If yes, state when: j) What is your employment? k) Religious affiliation: l) Racial background: m) Are you voluntarily relinquishing your parental rights? Yes (1) If yes, state reasons for seeking relinquishment: [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(8) and 15.3(a)] (2) Is your consent to the adoption attached? Yes (3) THE PARENT RELINQUISHING PARENTAL RIGHTS MUST PERSONALLY APPEAR IN COURT AT THE VOLUNTARY RELINQUISHMENT HEARING. [23 Pa.C.S.A. § 2503] 7 American LegalNet, Inc. www.FormsWorkFlow.com (4) The PUTATIVE FATHER has executed this petition voluntarily to promote what the PUTATIVE FATHER believes to be in her best interest and the ADOPTEE's best interest. [Pennsylvania Supreme Court Orphans' Court Rules Nos. 15.2(a)(9) and 15.3(a)] n) Explain the circumstances that created the status of PUTATIVE FATHER: o) A PUTATIVE FATHER'S parental rights may be terminated in these proceedings either by having the PUTATIVE FATHER join in this petition as a petitioner (this will require his testimony at the evidentiary hearing) OR by giving him NOTICE pursuant to 23 Pa.C.S.A. § 2503(d). Is the termination of the parental rights of a PUTATIVE FATHER an objective by either method? Yes p) 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. § 5103. [23 Pa.C.S.A. § 2503(d)] (1) Has a claim of paternity been filed? Yes (2) 23 Pa.C.S.A. § 2503(b) 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. § 5103 (relating to acknowledgements and claim of paternity) prior to the institution of proceedings. 5. State relationship of petitioner(s) to ADOPTEE: 6. If parental rights are being relinquished to an approved Agency, state name and address of the Agency: a) Pennsylvania Supreme Court Orphans' Court Rule 15.2(b)(4) requires "the joinder of the Agency having care of the child and its consent to accept custody of the child until such time as the child is adopted." Has the joinder and consent been completed? Yes 7. If a relinquishing 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 relinquished to adult(s) intending to adopt, is the identity of the proposed adoptive parent(s) known to the relinquishing parent(s)? Yes 8 American LegalNet, Inc. www.FormsWorkFlow.com a) b) 9. If yes, state name(s) and address(es) of proposed adoptive parent(s). Are proposed adoptive parents married? Yes 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. Is ADOPTEE's parent who is not a petitioner in these proceedings joining in the prayer of this petition? Yes a) If yes, Pennsylvania Supreme Court Orphans' Court Rules Nos. 15.2(c) and 15.3(c) require that person to testify at the hearing. b) 11. If no, the aforementioned Rules require notice to the other parent of the hearing on the petition. 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. § 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 12. Is birth certificate or certification of registration of birth of ADOPTEE attached as an Exhibit? [Pennsylvania Supreme Court Orphans' Court Rules 15.2(b)(2) and 15.3(b)] Yes a) 13. If no, see 23 Pa.C.S.A. § 2701(9) and question 1(m) in Adoption Petition form. Has/Have petitioner(s) received counseling concerning the termination of parental rights and the alternatives thereto from an approved agency or from a qualified counselor? Yes a) If yes, state the name and address of agency or counselor: 9 American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your petitioner(s) pray for Order(s) terminating the parental rights of the petitioner(s) and if required hereby terminate the parental rights of the Putative Father and award custody to the appropriate entity or parties. ________________________________________ ________________________________________ ________________________________________ [Signature(s) of Petitioner(s)] 10 American LegalNet, Inc. www.FormsWorkFlow.com COMMONWEALTH OF PENNSYLVANIA : : : COUNTY OF WESTMORELAND ss The above named petitioner(s), being duly sworn according to law depose(s) and say(s) that the facts set forth in the above Petition for Voluntary Relinquishment of Parental Rights are true and correct to the best of his/her/their knowledge, information and belief. ________________________________________ ________________________________________ ________________________________________ [Signature(s) of Petitioner(s)] Sworn to and subscribed before me this _____________ day __________________________, 20________ _____________________________________ (Signature of Notary) (SEAL OF NOTARY) 11 American LegalNet, Inc. www.FormsWorkFlow.com (Alternative Method for Verification) I/We the above named petitioner(s) do verify that the statements contained in this Petition for Voluntary Relinquishment of Parental Rights are true and correct to the best of my/our knowledge, information and belief. I/We 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 _______________________ ________________________________________________ ________________________________________________ ________________________________________________ [Signature(s) of Petitioner(s)] WITNESS ADDRESS OF WITNESS _______________________________ ________________________________________________ ________________________________________________ _______________________________ ________________________________________________ ________________________________________________ 12 American LegalNet, Inc. www.FormsWorkFlow.com CONSENTS TO ACCEPT CUSTODY CONSENT BY AGENCY: [Pennsylvania Supreme Court Orphans' Court Rule No. 15.2(b)(4)] We hereby certify that we are an approved AGENCY as defined in the Adoption Act and that [Adoptee] has been in our care and custody since and we agree to accept custody of the child/ADOPTEE until such time as the child/ADOPTEE is adopted, that we have read the foregoing petition, consent thereto and join in the prayer. Date:____________________________ ________________________________________________________ [Agency] By ______________________________________________________ _________________________________________________________ [Title] CONSENT BY ADULT(S): [Pennsylvania Supreme Court Orphans' Court Rule 15.3(b)] I/We [Name(s) of Adoptive Parent(s)] certify that the within named ADOPTEE has been in my/our custody since the day of , 20 . I/We agree to accept and continue custody until the Adoption is completed. I/We filed a Report of Intent to Adopt the ADOPTEE on the day of , 20 . My/Our present address is Date:____________________________ . _________________________________________________________ _________________________________________________________ [Name of Adult Intending to Adopt] 13 American LegalNet, Inc. www.FormsWorkFlow.com IN RE: Adoption of [Adoptee's Name on Birth Certificate] CONSENT TO ADOPTION OF BIRTH PARENT OR PUTATIVE FATHER WHO IS RELINQUISHING PARENTAL RIGHTS [23 Pa.C.S.A. § 2711(d)] 1. Name of person consenting to adoption of [Adoptee] 2. Age and date of birth of person consenting to the adoption: 3. Address of person consenting to the adoption: 4. Marital status of person consenting to the adoption: Married a) b) 5. If married, what is spouse's name: If married, what is the place and date of marriage: Relationship to person being adopted (ADOPTEE): a) b) Name and address of ADOPTEE'S birth father: c) 6. Name and address of ADOPTEE'S birth mother: If there is a putative father, state his name and address: Name of person being adopted (ADOPTEE): 14 American LegalNet, Inc. www.FormsWorkFlow.com 7. Adoptee: Age: Date of birth: Sex: Read the following carefully: I HEREBY VOLUNTARILY AND UNCONDITIONALLY CONSENT TO THE ADOPTION OF THE ABOVE NAMED ADOPTEE. I UNDERSTAND THAT BY SIGNING THIS CONSENT I INDICATE MY INTENT TO PERMANENTLY GIVE UP ALL OF MY RIGHTS TO THE ABOVE NAMED ADOPTEE. I UNDERSTAND THAT THE ABOVE NAMED ADOPTEE WILL BE PLACED FOR ADOPTION. I UNDERSTAND I MAY REVOKE THIS CONSENT TO PERMANENTLY GIVE UP ALL OF MY RIGHTS TO THE ABOVE NAMED ADOPTEE BY PLACING THE REVOCATION IN WRITING AND SERVING IT UPON THE AGENCY OR ADULT TO WHOM THE ADOPTEE WAS RELINQUISHED. IF I AM THE BIRTH FATHER OR PUTATIVE FATHER OF THE CHILD, I UNDERSTAND THAT THIS CONSENT TO AN ADOPTION IS IRREVOCABLE UNLESS I REVOKE IT WITHIN 30 DAYS AFTER EITHER THE BIRTH OF THE CHILD OR MY EXECUTION OF THE CONSENT, WHICHEVER OCCURS LATER, BY DELIVERING A WRITTEN REVOCATION TO (Name and Address of Agency) OR (Attorney’s Name and Address Representing the Relinquishing Parents or the Prospective Adoptive Parents) OR Judge , Westmoreland County Court of Common Pleas, Westmoreland County Courthouse, 2 N. Main Street, Greensburg, PA 15601. 15 American LegalNet, Inc. www.FormsWorkFlow.com IF I AM THE BIRTH MOTHER OF THE CHILD, I UNDERSTAND THAT THIS CONSENT TO AN ADOPTION IS IRREVOCABLE UNLESS I REVOKE IT WITHIN 30 DAYS AFTER EXECUTING IT BY DELIVERING A WRITTEN REVOCATION TO (Name and Address of Agency) OR (Attorney’s Name and Address Representing the Relinquishing Parents or the Prospective Adoptive Parents) OR Judge , Westmoreland County Court of Common Pleas, Westmoreland County Courthouse, 2 N. Main Street, Greensburg, PA 15601. I HAVE CAREFULLY READ AND UNDERSTAND THE ABOVE AND I AM SIGNING THIS CONSENT AS MY FREE AND VOLUNTARY ACT. ________________________________________________ [Signature of Consenter] Date:_____________________________ Place where read and signed: __________________________________ WITNESSES TO SIGNATURE: RELATION TO CONSENTER (1)_______________________________ [Signature of Witness] ________________________________________________ __________________________________ [Print or Type Name of Witness] __________________________________ [Address] __________________________________ 16 American LegalNet, Inc. www.FormsWorkFlow.com RELATION TO CONSENTER (2)_______________________________ [Signature of Witness] ________________________________________________ __________________________________ [Print or Type Name of Witness] __________________________________ [Address] __________________________________ 17 American LegalNet, Inc. www.FormsWorkFlow.com OPTIONAL1 I HEREBY VOLUNTARILY AND UNCONDITIONALLY GIVE MY CONSENT TO THE ADOPTION OF ADOPTEE WITHOUT THE DISCLOSURE OF THE NAMES OR OTHER IDENTIFICATION OF THE ADOPTING PARENTS OR PARENT. Date:_________________________ _________________________________________________________ [Signature of Consenter] 1 23 Pa.C.S.A. § 2712 CONSENT NOT NAMING ADOPTING PARENTS: "A consent to a proposed adoption meeting all the requirements of this part but which does not name or otherwise identify the adopting parent or parents shall be valid if it contains a statement that it is voluntarily executed without disclosure of the name or other identification of the adopting parent or parents." 18 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: ORDER OF TERMINATION (Voluntary Relinquishment) AND NOW, this _______ day of __________________________________ 20_____, after review of the record and after an evidentiary hearing following due notice the court makes the following findings and judicial determinations. 1. The petitioner(s) is . 2. The petitioner(s) is the birth parent(s) of the above captioned ADOPTEE. 3. Petitioner(s) has knowingly, deliberately and voluntarily relinquished all of his/her/their parental rights to ADOPTEE. 4. ALL OF PETITIONER(S) PARENTAL RIGHTS TO ADOPTEE ARE HEREBY FOREVER TERMINATED AND ADOPTEE MAY BE ADOPTED WITHOUT FURTHER CONSENT OF OR NOTICE TO PETITIONER(S). 5. The custody of ADOPTEE is hereby transferred to-a) OR b) an approved Agency and such Agency is hereby authorized to give consent to the adoption of ADOPTEE. 6. (Name of Putative Father) putative father of ADOPTEE having received proper and due notice in accordance with 23 Pa.C.S.A. § 2503 and has failed to file an acknowledgement of paternity pursuant to 23 Pa.C.S.A. § 5103 has failed to appear or file written objections as required by 23 Pa.C.S.A. § 2503. THE PARENTAL RIGHTS OF SAID PUTATIVE FATHER ARE HEREBY TERMINATED pursuant to 23 Pa.C.S.A. § 2503 and the adoption of ADOPTEE may continue without further consent of, or notice to said putative father. 19 American LegalNet, Inc. www.FormsWorkFlow.com The Adoptive Parent(s) is/are directed to file his/her/their Petition for Adoption within sixty (60) days after the conclusion of the appeal period. BY THE COURT: ____________________________________, J. ATTEST: ______________________________________ 20 American LegalNet, Inc. www.FormsWorkFlow.com