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. __________________ REPORT OF THE INTERMEDIARY IN THE ADOPTION OF A FOREIGN BORN CHILD The report of the agency, _______________________________________, as intermediary, under 23 Pa. C.S. � 2533, states as follows: Intermediary's address 1. Intermediary's telephone no County where office is located: 2. The facts as to the adoptee child are: a) Name b) Sex c) Racial background d) Age e) Birth date f) Birthplace g) Religious affiliation Date of the placement of the child with the Petitioner(s), adopting parent(s), If known, the facts as to the birth mother are: a) Name b) Residence or last known address c) Racial background d) Age e) Marital status as of the time of the birth of the child f) Marital status during one year prior to birth of the child g) Religious affiliation h) Birth mother's parental rights were terminated by decree of ___________________________________________ dated 5. 3. 4. If known, the facts as to the birth father are: a) Name b) Residence or last known address c) Racial background d) Age e) Marital status as of the time of the birth of the child American LegalNet, Inc. www.FormsWorkFlow.com f) Marital status during one year prior to birth of the child g) Religious affiliation h) Birth father's parental rights were terminated by decree of _________________________________________dated 6. All consents required by 23 Pa. C.S. � 2711 are attached to this Report as exhibits or are not required for the following reasons, provide explanation: 7. A true and correct copy of the birth certificate or a registration of the birth by the country of birth is attached to this Report as an exhibit. 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 attached as exhibits to this Report. a) b) 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, 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 decrees and/or documents. 8. Attach a verified list of itemized fees and/or expenses paid or to be paid to or received by the intermediary and/or any other person or persons to the knowledge of the intermediary by reason of the adoption placement. A full description and statement of the value of all property owned or possessed by the child, if any, is as follows: 9. 10. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of the child. The child's medical history information was obtained and is available, except as 11. follows: DATE: __________________ ________________________________ Signature (Type name of signor, title, and name of agency) American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION TO REPORT OF INTERMEDIARY I,______________________________, (Title) verify that I am _______________________________________________ of _________________ _____________________________________________________________________ (Name of Agency) and I am authorized to take this verification on its behalf, and that the facts set forth in the foregoing Report are true and correct to the best of my knowledge, information and belief. I further verify that all documents attached to this Report are true and correct copies of the originals. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. � 4904 relating to unsworn falsification to authorities. DATE: ____________________ _____________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com