Birth Parents Affidavit And Petition To Appoint Confidential Intermediary (Child)
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Birth Parents Affidavit And Petition To Appoint Confidential Intermediary (Child) Form. This is a Wyoming form and can be use in Park Local County.
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Tags: Birth Parents Affidavit And Petition To Appoint Confidential Intermediary (Child), WYOAI-1, Wyoming Local County, Park
STATE OF WYOMING
)
)
)
STATE OF WYOMING
COUNTY OF PARK
WYOAI-1
(12/31/91)
SS
IN THE MATTER OF THE ADOPTION
OF
______________________________
IN THE DISTRICT COURT
FIFTH (5TH) JUDICIAL DISTRICT
)
) CASE # ____________
)
) BIRTH PARENT'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:
I was born on __________ and I am 19 years of age or older.
_______________________________
My current telephone number is: (___)_______-_________. My current address is: ____________
_____________________________________________________________________________.
I was adopted by ____________________________________________________ in
______________________________ (date of adoption).
I know the following about my birth parents or relatives: ____________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I am seeking my birth parents or relatives because: _________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I am/am not living with my adoptive parents.
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, government agencies, and
hospitals.
DATED this ______ day of _______________________________, 20 _______.
_________________________________
(Petitioner's Signatures)
SUBSCRIBED AND SWORN to before me this ______ day of ______________ 20_____.
My commission expires:
__________________
___________________________
NOTARY PUBLIC OR DEPUTY
CLERK OF COURT
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