IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA, ORPHANS222 COURT DIVISION : : :IN RE: Adoption of No.(Adoptee222s name exactly as it appears on birth certificate) PETITION FOR INVOLUNTARY TERMINATION OF PARENTAL RIGHTS 23 Pa.C.S. 2472512 The following is respectfully represented: TO THE HONORABLE, THE JUDGE OF SAID COURT: 1.List name(s) and address of petitioner(s), if no intermediary:(See 23 Pa.C.S. 2472512)a.Name:Address:b.Name:Address:2.Age of petitioner(s):a. b. 3.If petitioner(s) is an approved Agency or Institution, list complete name and address:a.Name:b.Address:4.Relationship of petitioner(s) to adoptee:Form A-2512 7/2018 5.If required, petitioner(s) has filed a Report of Intention to Adopt.(23 Pa.C.S. 2472472531 & 2532)Date of filing: 6.Petitioner will assume custody of the adoptee until such time as the child is adopted.(23 Pa.C.S. 2472512(b))1 American LegalNet, Inc. www.FormsWorkFlow.com 7.ADOPTEE INFORMATIONa.Name exactly as it appears on birth certificate:b.Date of birth:c.Place of birth:d.Age:Sex: Male Femalee.Racial background:f.Religious affiliation, if any:g.Present residence of the adoptee:h.Name of individual/agency/institution who has custody of the adoptee and date placed in care.i.Was the adoptee born out of wedlock? Yes No8.Natural Mother Informationa.Name:b.Maiden name, if applicable:c.Present address:d.If unknown, list last known address:e.Date of birth:Age: f.Racial Background:g.Religious affiliation, if any:h.Present marital status:If married, list the name of the spouse:Date and place of marriage:i.If the natural mother was married at the time of the adoptee222s birth, list the name ofthe spouse: (Pa. Orphans222 Court Rule 15.4(4))2 Form A-2512 7/2018 American LegalNet, Inc. www.FormsWorkFlow.com If this marriage ended, state nature of dissolution and date: j.If the natural mother was married one year prior to the adoptee222s birth, list the name ofthe spouse: (Pa. Orphans222 Court Rule 15.4(4))3 9.Is the petition requesting the termination of parental rights of the natural mother? Yes NoIf this marriage ended, state nature of dissolution and date: 10.NATURAL FATHER INFORMATIONa.Name:b.Present address:d.Date of birth:Age: e.Racial Background:f.Religious affiliation, if any:g.Present marital status:If married, list the name of the spouse: Date and place of marriage: c.If unknown, list last known address:11.Is the petition requesting the termination of parental rights of the natural father? Yes No12.PUTATIVE FATHER INFORMATION(Complete section if applicable.) a.Name:b.Present address:c.If unknown, list last known address:Form A-2512 7/2018 American LegalNet, Inc. www.FormsWorkFlow.com d.Date of birth:Age: e.Racial background:f.Religious affiliation, if any:g.Present marital status:If married, list the name of the spouse: h.If the putative father married the natural mother, state date of marriage anddissolution, if applicable: i.Explain creation of the status of the putative father:13.Set forth the ground(s) for involuntary termination of parental rights, including the specificsubsection(s) of 23 Pa.C.S. 247 2511(a)(1), which establish(es) the legal basis for the requested termination(s): (23 Pa.C.S. 247 2512(b)) 14.The original birth certificate or certification of registration of birth of the adoptee is attached.(Pa. Orphans222 Court Rule 15.4(b)(1)) 15.List the name(s) of those person(s) whose parental rights may be terminated by these proceedings,who is/are a member of the United States Armed Services and thereby entitled to the benefits of the Soldiers222 and Sailors222 Civil Relief Act of 1940 as amended, 50 U.S.C.A. 247501 et seq.: (Pa. Orphans222 Court Rule 15.4(a)(7)) 4 Form A-2512 7/2018 American LegalNet, Inc. www.FormsWorkFlow.com 16.As soon as the petitioner(s) or attorney(s) has/have reason to believe these proceedings will becontested, the court must be notified IMMEDIATELY to avoid delay. 17.If the child was born in the Commonwealth of Pennsylvania, official certificates have beenrequested from the Pennsylvania Department of Welfare identifying any paternity acknowledgments or paternity claims on file with the Department in accordance with 23 Pa.C.S. 2475103 (b). (York County Orphans222 Court Rule 15.4.1)WHEREFORE, the petitioner(s) pray the Court for termination of the rights of parental rights as requested herein to said child and for a decree of termination of all such rights as provided in 23 Pa.C.S. 2472521, so that such child may be adopted to such parents and without further consent of, or notice to,those individuals whose parental rights are terminated. Attorney for Petitioner(s) Individual Petitioner Individual Petitioner Parent and or Guardian, if Petitioner is under the age of eighteen (18) years, unless excused by this Court. Agency Authorized Signature 5ByForm A-2512 7/2018 American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION This day of , 20 , the foregoing Petitioner(s) hereby verify, subject to the penalties of 18 Pa.C.S. 2474904 (relating to unsworn falsification to authorities), that the facts set forth in the foregoing petition which are within their knowledge are true, and as to the facts based on information received, after diligent inquiry, petitioner(s) believe them to be true. Individual Petitioner Individual Petitioner Parent and or Guardian, if Petitioner is under the age of eighteen (18) years, unless excused by this Court. Agency Authorized Signature 6 ByForm A-2512 7/2018 American LegalNet, Inc. www.FormsWorkFlow.com