FC-47 (revised September 2013) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT ADOPTION PETITION (A child under eighteen (18) years of age) JUVENILE NUMBER DATE FILED PETITION NUMBER PETITIONER NAME: (LAST, FIRST, MIDDLE) DATE OF BIRTH/AGE RACE RELATIONSHIP TO JUVENILE TELEPHONE NUMBER PETITIONER NAME: (LAST, FIRST, MIDDLE) DATE OF BIRTH/AGE RACE RELATIONSHIP TO JUVENILE ADDRESS) TELEPHONE NUMBER JUVENILE NAME: (LAST, FIRST, MIDDLE) DATE OF BIRTH /AGE RACE SEX CHILD HAS RESIDED WITH PETITIONER ( S ) SINCE (DATE) ADDRESS NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER PARENT, GUARDIAN, ETC. (LAST, FIRST, MIDDLE) DATE OF BIRTH/AGE RELATIONSHIP TO JUVENILE (OR DATE OF DEATH) TELEPHONE NUMBER PARENT, GUARDIAN, ETC. (LAST, FIRST, MIDDLE) DATE OF BIRTH/AGE RELATIONSHIP TO JUVENILE TELEPHONE NUMBER ADDRESS BAR NUMBER TELEPHONE NUMBER The above - named petitioner(s) aver they are desirous of adopting the above - named child who has resided with said petitioner(s) as indicated above; that said parent(s)/guardian(s) of said child are as listed above; that o be changed to: FIRST MIDDLE LAST Witness: DATE PETITIONER DATE Witness: DATE PETITIONER DATE The undersigned and of said child hereby consent(s) to said adoption. Witness : DATE PARENT, GUARDIAN, ETC. DATE Witness : DATE PARENT, GUARDIAN, ETC. DATE I, the above-named child, being of the age of fourteen (14) years and upwards, hereby consent to said adoption. Witness: DATE CHILD DATE American LegalNet, Inc. www.FormsWorkFlow.com