Rev. 5/2011 IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION In re Adoption of: __________________________________________ (Adoptee's name exactly as it appears on birth certificate) : : : : No. _____________ PETITION FOR ADOPTION UNDER 23 Pa.C.S. �2701 Petitioner(s) must comply with Pa.O.C. Rule 15 and Y.C.O.C.R. 15.1.1-15.5.5 1. The full name(s) of each Petitioner(s) is/are ______________________________________ and ________________________________________ a. The marital status of each Petitioner is ____________________________________ b. If married, Petitioners were married on ___________________________________ c. Petitioner(s) reside at _________________________________________________ where they have resided continuously since _____________________________________ d. The phone number(s) for Petitioner(s) is/are _______________________________ 2. Additional facts as to Petitioner ______________________________________ (husband) are: a. Date of Birth: b. Birthplace: c. Social Security No.: d. Religious Affiliation: e. Racial Background: f. Occupation: g. Employer: h. Income: i. Relationship, if any, to adoptee: 3. Additional facts as to Petitioner ______________________________________ (wife) are: a. Date of Birth: b. Birthplace: c. Social Security No.: d. Religious Affiliation: e. Racial Background: f. Occupation: g. Employer: h. Income: i. Relationship, if any, to adoptee: 4. The following facts are alleged regarding the proposed adoptee: a. Full Name: b. Sex: c. Date of Birth: d. Racial Background: 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. Said adoptee has resided continuously with Petitioner(s) since: ___________________________ 6. Petitioners desire to adopt the said adoptee as one of their heirs, with the establishment of relationship of parent and child and declare that they will perform all the duties of parents to said adoptee. 7. The reports under 23 Pa.C.S. �2530 (relating to Home Study and Pre-Placement Report), �2531 (relating to Report of Intention to Adopt) and �2533 (relating to Report of Intermediary) have been filed on _________________ , if required. If these reports were not filed, the reason(s) they are not required are: 8. All consents required by 23 Pa.C.S. �2711 (relating to consents to adoption) are attached as exhibits to this Petition. If not, the reasons those consents are not required are as follows: 9. All other exhibits required by 23 Pa.C.S. �2702 are attached to this Petition, including the following exhibits enumerated in �2534: a. Adoptee's birth certificate or registration of birth. If not available compliance with �2701(9) is required. b. Certified copy of any decree of termination of parental rights by another court. If these exhibits are not attached to this Petition, the reasons those exhibits are not attached are as follows: 10. All background reports and clearances as required by 23 Pa.C.S. �6344 and Y.C.O.C.R. 15.1.2(c) have been filed on ______________________ or are being filed with this Petition. 11. The name and address of the intermediary, if any: 12. If there is no intermediary or if no report of the intermediary has been filed or if the adoptee is age 18 or older, all vital statistics and other information enumerated and required to be stated of record by 23 Pa.C.S. �2533, so far as applicable, are represented as follows: 13. Petitioner(s) desire the minor adoptee's name be changed to _____________________________ if the Court grants this Petition for Adoption. (See Y.C.O.C.R. 15.5.2 for an alternative procedure for an Adult Adoptee seeking a change of name) 2 American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your Petitioner(s), believing and alleging that the welfare of the said adoptee will be promoted by the adoption, pray your Honorable Court for a Decree of Adoption providing that the person proposed to be adopted shall have all the rights of a child and heir of your Petitioner(s) and be subject to the duties of such child. ________________________________ , Petitioner ____________ Date ________________________________ , Petitioner ____________ Date _______________________________ Attorney for Petitioner(s) Full Name: Address: Phone No.: Supreme Court ID No.: VERIFICATION I, Petitioner, verify that the statements made in this Petition for Adoption are true and correct to the best of my knowledge, information, and belief. I understand that the statements made herein are made subject to the penalties of 18 Pa.C.S. �4904 relating to unsworn falsification to authorities. ________________________________ , Petitioner _____________ Date ________________________________ , Petitioner _____________ Date 3 American LegalNet, Inc. www.FormsWorkFlow.com CONSENT BY ADOPTEE I, the undersigned proposed adoptee named in the within Petition for Adoption, being over twelve (12) years of age, hereby assure the Court that I fully understand the nature and consequence of the adoption and hereby consent to my adoption as requested in the within Petition. ________________________________ Signature of Adoptee _____________ Date The undersigned two witnesses hereby certify that the above adoptee signed the above consent in our presence on the above date. Printed Name Address Relationship to Adoptee 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ ________________________________ Signature of First Witness ________________________________ Signature of Second Witness 4 American LegalNet, Inc. www.FormsWorkFlow.com