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 TO CONFIRM CONSENT TO ADOPTION 23 Pa.C.S. 2472504TO THE HONORABLE, THE JUDGE OF SAID COURT: The following is respectfully represented: 1.List full name (including complete middle name) and address of petitioner(s), if no intermediary:a)Name: b)Address: 2.If petitioner is an intermediary, state complete name and address: b)Address: 3.This petition is filed with respect to:a.Name :(Exactly as it appears on birth certificate) b.Date of birth: c.Place of birth: d.Age: Sex: 4.Biological mother information:a.Name :(Exactly as it appears on birth certificate) b.Present address: c.If unknown, list last known address: d.Date of birth: Age: a)Name:Form A2504 1Revised 05/ 2018 American LegalNet, Inc. www.FormsWorkFlow.com 5.Legal father information:a.Name :(Exactly as it appears on birth certificate) b.Present address: c.If unknown, list last known address: d.Date of birth: Age: e.Is he also the biological father? 6.Putative father information:a.Name :(Exactly as it appears on birth certificate) b.Present address: c.If unknown, list last known address: d.Date of birth: Age: e.Circumstances indicating the putative father222s status:7.Such parent, parents or putative father has/have executed consent or consents to this adoption.The original(s) is/are attached to this petition. 8.Any Putative father:a. executed a consent to the adoption; and, (Choose one: Has / has not)b. filed an acknowledgment of paternity or claim of paternity pursuant to 23 Pa.C.S. 2475103. (Choose one: Has / has not)2 American LegalNet, Inc. www.FormsWorkFlow.com Individual Petitioner Individual Petitioner Intermediary Attorney for Petitioner(s) By Authorized SignatureVERIFICATION This day of , 20, the foregoing Petitioner(s) hereby verify, subject to the penalties of 18 Pa.C.S. 2474904 (relating to unsown 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 Intermediary By Authorized Signature 3WHEREFORE, the petitioner(s) pray the Court to hold a hearing for the purpose of confirming theintention of the parent, parents, or putative father to voluntarily relinquish their rights and duties as evidenced by the consents to the adoption and to enter a decree terminating their parental rights duties as provided in 23 Pa.C.S. 2472504. American LegalNet, Inc. www.FormsWorkFlow.com ORDER OF COURT AND NOW, TO WIT, THIS day of , 20, the foregoing petition is ordered filed, and a private hearing thereon is fixed for at , in Room No. in the York County Judicial Center, York, PA. At least ten (10) days222 notice of the hearing in the form prescribed by 23 Pa.C.S. 2472513 (b) shall be given by personal service or by registered or certified mail, at the present or last known address, to the parent, parents or putative father listed in the petition, and to the parent or guardian of any who have not reached 18 years of age. Notice shall state the parental rights of the parent, parents or putative father may be terminated as a result of the hearing. , Esquire, is hereby appointed to represent the child listed in paragraph 3 of the petition.BY THE COURT: Judge 4 American LegalNet, Inc. www.FormsWorkFlow.com