JC-1640, 02/18 Petition for Adoptive Placement 24748.837, Wisconsin Statutes; 25 U.S.C. 2471915. This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF a person under the age of 18 Date of Birth Petition for Adoptive Placement Case No. UNDER OATH, I STATE: 1 . A . The child was born on the date indicated above and resides at B. The child is due to be born about . 2. The birth mother , age , resides at . 3. The birth father , age , resides at . 4. The proposed adoptive Parent 1 , age , resides at . 5. The proposed adoptive Parent 2 , age , resides at . 6. [Person/agency] arranged placement of the child. 7. The report of financial, medical and legal arrangements is attached. 8. The placement is in a licensed foster home. 9. The Petition for Termination of Parental Rights accompanies this Petition. 10. A. The child is not subject to the federal Indian Child Welfare Act. B. The child is subject to the federal Indian Child Welfare Act, and: (1) (2) : (if applicable) (3) Placement has been made in accordance with the order of preference set forth in the Indian Child Welfare Act. OR There is good cause to depart from the order of placement preference in the Indian Child Welfare Act: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Petitioner Name Printed or Typed Date DISTRIBUTION: 1. Court 2. Parties 3. Tribe (if any) American LegalNet, Inc. www.FormsWorkFlow.com