WYCAI-4 (1/27/11) STATE OF WYOMING ) ) COUNTY OF ________________________) IN THE MATTER OF THE ADOPTION OF IN THE DISTRICT COURT SS ____________________JUDICIAL DISTRICT ) ) ) ) ) ) CASE # ________________________________ BIRTH GRANDPARENT'S AFFIDAVIT AND PETITION TO APPOINT A CONFIDENTIAL INTERMEDIARY, PURSUANT TO W.S. 1-22-203(b) _______________________________ ___________________________________________, being first duly sworn, on oath, petitions and says: (petitioner's name) My telephone numbers are: (home) _______________________(work)___________________________ (cell) ___________________________. E-mail address _______________________________________ Mailing address_______________________________________________________________________. My birth grandson/granddaughter was born in ______________________________________on (city/county) ______________________________________and is 18 years of age or older. (date of birth) Date of relinquishment: ___________________City/County _____________________________. Birth parents' names at the time of relinquishment: _____________________________________ The adoption was finalized in ______________________________________Unknown _______ (City County) I know the following about my birth grandson's/granddaughter's adoptive family: ___________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I am seeking my birth grandson/granddaughter because: ________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I, therefore, petition this court and respectfully request that an order be entered appointing a confidential intermediary, pursuant to W.S. 1-22-203(b) and that the confidential intermediary be allowed to inspect and copy, at the petitioner's expense, the pertinent adoption files of the court, governmental agencies, adoption agencies and hospitals. DATED this ______________day of ___________________________________________, 20 _______. _____________________________________________ (Petitioner's signature) SUBSCRIBED AND SWORN to before me this __________ day of __________________, 20________. My commission expires: ___________________________________ _____________________________________________ NOTARY PUBLIC OR DEPUTY CLERK OF COURT American LegalNet, Inc. www.FormsWorkFlow.com