IN THE COURT OF COMMON PLEAS OF _____________________________ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION (FAMILY COURT DIVISION in Philadelphia County) IN RE: ADOPTION OF ________________ (initials only) ADOPTION NO. _____________________ PETITION FOR ADOPTION OF A FOREIGN BORN CHILD To the Honorable, the Judge of said Court: The Petition of__________________________________________________ under (Name(s) of Adopting Parent(s)) 23 Pa. C.S. §§ 2701 and 2908 respectfully states that: 1. At least one of the Petitioners filing this Petition is a resident of the Commonwealth of Pennsylvania and has resided in this Commonwealth since __________________________________________________________________ (Provide at least month and year) 2. No other court in this Commonwealth or in any other state has reviewed, registered, finalized or otherwise assumed jurisdiction over the adoption of this child, except as follows: ___________________________________________________ (Provide name of court, county and state) Explain the proceeding previously initiated and the resulting decision from the court: (Attach all court decrees). 3. Petitioner(s) desire(s) to adopt this child known as ___________________________________________________________________ (Name of child as written on Foreign Decree) and intend that such child shall be treated as one of (his/her/their) heirs and hereby declare(s) that (he/she/they) will perform all the duties of parent(s) to him/her. 4. The child has entered the United States pursuant to a United States visa. A true and correct copy of the United States visa is attached as an exhibit to this Petition. The United States visa was issued as an: (Please circle one) 5. IR-2, IR-3, IH-3, IR-4 or IH-4 a) The child's full name as shown on the United States visa is ______________________________________________________________ b) The full birth name of the child as listed on the foreign birth certificate (if American LegalNet, Inc. www.FormsWorkFlow.com available) is ______________________________________________________________ c) The full name of the child as it appears on the foreign decree is ______________________________________________________________ d) The full name of the child as he/she is to be known from this time forward is ______________________________________________________________ 6. 7. The child has resided with Petitioner(s) for the following length of time ______ ______________________________________________________________ Information concerning the Petitioner(s), the adopting parent(s), is as follows: a) Adopting Father: 1) 2) 3) 4) 5) 6) 7) 8) 9) Full name Residence Marital status Age Occupation Religious affiliation Racial background Relationship to adoptee by blood or marriage, if any Daytime telephone no. b) Adopting Mother: 1) 2) 3) 4) 5) 6) 7) 8) 9) Full name Residence ________________________________________________ Marital status Age Occupation Religious affiliation Racial background Relationship to adoptee by blood or marriage, if any Daytime telephone no. 8. The following reports, as applicable, have been completed as of the dates set forth below. A true and correct copy of each of these reports is attached as an exhibit to this Petition. a) Report of Intermediary described in 23 Pa. C.S. § 2533 b) Home Study and/or Preplacement Reports described in 23 Pa. C.S. § 2530 c) Investigation Reports described in 23 Pa. C.S. § 2535 d) Postplacement Reports, if any 9. Information concerning the intermediary agency, if any, is as follows: Name of agency Address Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com County where office is located 10. If there is no report of an intermediary, the following information is being provided by the Petitioner(s) as to the adoptee child: a) Sex b) Racial background c) Age d) Birth date e) Birthplace f) Places of residence since birth g) Religious affiliation h) A full statement of the value of all property owned or possessed by the child, if any i) State whether medical history information was obtained, and if not, explain why not 11. If there is no report of an intermediary, and the adoptee child is under 18 years of age, provide the following information as to the birth mother, if known: a) Name b) Residence or last known address c) d) e) f) g) h) Racial background Age Marital status as of the time of the birth of child Marital status during one year prior to birth of child Religious affiliation Birth mother's parental rights were terminated by decree of _______________________________________ dated 12. If there is no report of an intermediary, and the adoptee child is under 18 years of age, provide the following information as to the birth father, if known: a) Name b) Residence or last known address c) d) e) f) g) h) Racial background Age Marital status as of the time of the birth of child Marital status during one year prior to birth of child Religious affiliation Birth father's parental rights were terminated by decree of ______________________________________ dated 13. If there is no report of an intermediary, attach a copy of the birth certificate. If no birth certificate or other birth identification issued by the country of birth can be obtained, a statement of the reason and a detailed explanation of the efforts made to obtain the certificate are required and attached as an exhibit to this Petition. American LegalNet, Inc. www.FormsWorkFlow.com 14. If there is no report of an intermediary, attach copies of any foreign decrees and/or documents concerning this adoption, including any decree terminating the parental rights of birth mother and/or birth father, if needed, with an English translation for those decrees and/or documents not in English, certified by a translator to be true and correct translations of the foreign decrees and/or documents. 15. If there is no report of an intermediary, attach all consents required by Section 2711 of the Adoption Code, 23 Pa. C.S. § 2711. If consents are not required, explain: 16. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed. 17. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency. 18. Attach U.S. Government Form N-560, Certificate of Citizenship, and/or a copy of the child's United States passport, if either or both documents are availa