Revised 05/2018 1 IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA ORPHANS222 COURT DIVISION In Re: : : Adoption of : No. : (Adoptee222s name as on birth certificate) : REPORT OF INTENTION TO ADOPT PURSUANT TO 23 Pa.C.S. 2472531 The following is respectfully reported to the Court: 1. The name(s) and address(es) of the undersigned are: 2. The date and circumstances surrounding the retention of custody or physical care of the child under eighteen (18) years of age are: 3. A pre-placement investigation, if conducted was concluded on . A copy of the pre-placement report, prepared pursuant to 23 Pa.C.S. 2472530 is attached. 4. The following is pertinent information with respect to such child: a. Name: b. Date of Birth: c. Place of Birth: d. Age: e. Sex: f. Racial background: g. Religious affiliation (if any): 5. The name and address of the intermediary: American LegalNet, Inc. www.FormsWorkFlow.com 2 6. A Complete itemization of all moneys and consideration paid or to be paid to the intermediary is as follows: $ $ $ 7. The natural parent(s) Has/have received counseling with respect to the termination of parental rights and the alternative thereto. The following is the name and address of the agency or counselor who provided the counseling and the dates on which the counseling occurred: a. Name and address of agency or counselor: b. Date(s) of counseling: Has/have not received counseling with respect to the termination of parental rights and the alternatives thereto. Respectfully submitted this day of , 20. I acknowledge that I have been advised or know and understand that the BIRTH father or putative father may revoke the consent to the adoption of this child within thirty (30) days after the later of the birth of the child or the date he has executed the consent to an adoption and that the BIRTH mother may revoke the consent to an adoption of this child within thirty (30) days after the date she has executed the consent. Attorney for Petitioner(s) ,Petitioner Name: Address: ,Petitioner Phone No.: Supreme Court ID No.: American LegalNet, Inc. www.FormsWorkFlow.com 3 IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA ORPHANS222 COURT DIVISION In Re: : : No. Adoption of : : (Adoptee222s Name as on Birth Certificate) : ORDER AND NOW, TO WIT, this day of , 20, the foregoing Report of Intention to Adopt is ordered filed and is hereby appointed to make an investigation and report covering all pertinent information regarding the suitability of the placement as required by 23 Pa.C.S. 2472535. Any costs of such investigation shall be paid by the proposed adopters. By the Court: Judge American LegalNet, Inc. www.FormsWorkFlow.com