THE COURTS
FRANKLIN AND FULTON COUNTIES
Amendment of Orphan's Court Procedure 39-15 and 39-16; Miscellaneous Doc. Volume 5, Page 241
[38 Pa.B. 596]
[Saturday, February 2, 2008]
Order of Court December 26, 2007, it is hereby ordered that Local Rules of Orphan's Court Procedures 39-15 and 39-16 are amended, as follows, said rule will be effective thirty (30) days after publication in the Pennsylvania Bulletin.
By the Court
JOHN R. WALHER,
President Judge
Proposed Changes to Orphan's Court Local Rules Regarding Adoptions for Franklin and Fulton Counties
RULE 39-15. ADOPTIONS Rule 39-15.1. Practice and Procedure.
(a) Reports and Petitions; Fees. All reports and petitions relating to adoption shall be filed with the Clerk of Courts and shall be in such form as is designated from time to time by the Court. All filing fees shall be paid at the time of filing. The Clerk shall, at the time of filing, assign each case a docket number, volume number and page number. Upon the completion of any proceedings relative to adoption, all documents in connection therewith shall be handled in the manner set forth in Pa.O.C.R. 15.7.
(b) Request for Investigation. If no report of intention to adopt is required, in the absence of a special order of court, there shall be no investigation of the petition for adoption. If an investigation of the adoption petition is necessary, the Court shall order the investigating agency to conclude its investigation and file its report not later than ninety (90) days after the filing of the notice of intention to adopt.
(c) Counseling fund. Pursuant to 23 Pa.C.S.A. § 2505(e), a fund has been established by the county to provide funding for counseling pursuant to 23 Pa.C.S.A. § 2505(c) or (d) for those who are unable to pay for such counseling. A parent who cannot afford to pay for counseling may petition the Court for payment of counseling by the fund. If the Court finds that the parent is unable to pay for counseling and desires counseling, the Court shall order payment from the fund.
Rule 39-15.5.4. Involuntary Termination of Parental Rights.
(a) Notice and Hearing. A hearing for involuntary termination of parental rights under 23 Pa.C.S.A. § 2513 shall be at a separate time and on a separate day from the hearing on the petition for adoption.
Rule 39-15.5.5. Adoption.
(a) Hearing. Unless otherwise ordered by the Court, the hearing on the petition for adoption shall be private.
(b) Proposed Order. At the conclusion of the hearing for adoption, the petitioners shall submit to the hearing judge a proposed decree.
Rule 39-15.5.8. Confirmation of Consents.
(a) Hearing. The hearing for confirmation of consents under 23 Pa.C.S.A. § 2504(a) shall be at a separate time and on a separate day from the hearing on the petition for adoption, and shall be held at least thirty (30) days prior to the hearing on the petition for adoption.
(b) Notice. Notice of the hearing on confirmation of consents shall be given to each parent as directed in Pa.O.C.R. 15.6 and 23 Pa.C.S.A. § 2504(b) and in the form directed in 23 Pa.C.S.A. § 2513(b).
Rule 39-16. Forms.
(a) Consent of a child over the age of 12. A child over the age of 12 shall consent to his or her adoption and shall sign a consent form in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
CONSENT TO ADOPTION BY ADOPTEE
(Consent of proposed adoptee over 12 years of age)
23 Pa.C.S.A. § 2711(a)(1)I, , the above proposed adoptee, aged , do hereby certify that I have read the petition in the above-captioned matter and fully understand the contents thereof and do hereby, without reservation, give my consent to my adoption by the petitioners in the above-captioned matter.
I have read and understand the above and I am signing it as a free and voluntary act. In Witness Whereof, I have hereunto set my hand and seal this day of , 20 , at .
_________________
(Signature of Consenter)WITNESSES:
______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)STATE OF ______
COUNTY OF ______
On this, the ____ day of ______ , 20 ____ , before me, ______ , the undersigned officer, personally appeared ______ , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_________________
(signature of notary public)
Title __________
My commission expires: __________
I maintain my office in __________(b) Consent by biological parent. A biological parent who is not a petitioner in the adoption action shall sign a consent to the adoption of the child in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
CONSENT TO ADOPTION
23 Pa.C.S.A. § 2711(a) and (d) _________________ __________
(Name of Consenting Parent) Age
_________________ __________
(Marital Status) (Relationship to Child)
_________________
(Name of Other Parent)I hereby voluntarily and unconditionally consent to the adoption of , born .
I understand that by signing this consent I indicate my intention to permanently give up all rights to this child.
I understand such child will be placed for adoption.
I understand I may revoke this consent to permanently give all rights to this child by placing the revocation in writing and serving it upon the agency or adult to whom the child is relinquished.
If I am the birth father or putative father of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within 30 days after either the birth of the child or my execution of the consent, whichever occurs later, by delivering a written revocation to __________[insert the name and address of the agency coordinating the adoption] or ______ [name and mailing address of attorney representing the individual relinquishing parental rights or prospective adoptive parent(s) of the child] or the Clerk of Courts for the Orphans Court of the Court of Common Pleas of the 39th Judicial District, Pennsylvania--Franklin County Branch, 157 Lincoln Way East, Chambersburg, PA 17201.
If I am the birth mother of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within 30 days after executing it by delivering a written revocation to [insert the name and address of the agency coordinating the adoption] or [name and mailing address of attorney representing the individual relinquishing parental rights or prospective adoptive of the child] or the Clerk of Courts for the Orphans Court of the Court of Common Pleas of the 39th Judicial District, Pennsylvania--Franklin County Branch 157 Lincoln Way East, Chambersburg, PA 17201.
{I acknowledge that the adopting parent(s) name(s) [is][are] .} or
{I hereby certify that this consent is being voluntarily executed without the disclosure of the name or other identifying information of the adopting parent or parents.}
I have read and understand the above and I am signing it as a free and voluntary act.
Date: ______ __________(Signature of Consenter)
Place of execution: __________
WITNESSES:
______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)STATE OF ______
COUNTY OF ______
On this, the ____ day of ______ , 20 ____ , before me, ______ , the undersigned officer, personally appeared ______ , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_________________
(signature of notary public)(c) Consent of Guardian or Person with Custody: The guardian of the child or person or agency with custody of the child shall sign a consent to the adoption of the child in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
CONSENT TO ADOPTION BY [GUARDIAN] [PERSON HAVING CUSTODY OF ADOPTEE]
23 Pa.C.S.A. § 2711(a)(5) [I] [We], , [being the guardian of] [having custody of] [do][does] certify without disclosure of the name or other identification of the adopting parent(s) the [I] [we] have read the petition in the above captioned matter and fully understand the contents thereof, and without any undue influence or coercion exerted upon [me] [us] by any person, [I] [We] willingly and of [my] [our] own volition surrender all of [my] [our] rights in and to said adoptee, and believing that it will promote [his] [her] welfare, give consent to [his] [her] adoption.
I have read and understand the above and I am signing it as a free and voluntary act. In Witness Whereof, I have hereunto set my hand and seal this day of , 20 , at .
_________________
(Signature of Consenter)WITNESSES:
______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)STATE OF ______
COUNTY OF ______
On this, the ____ day of ______ , 20 ____ , before me, ______ , the undersigned officer, personally appeared ______ , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_________________
(signature of notary public)
Title __________
My commission expires: __________
I maintain my office in __________(d) Consent of spouse or natural parent in a step-parent adoption: The spouse of the adopting parent shall sign a consent to the adoption of the child in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
CONSENT TO ADOPTION BY [ADOPTING PARENT'S SPOUSE] (if not joining in petition) [NATURAL PARENT IN STEP-PARENT ADOPTION]
23 Pa.C.S.A. § 2711(a)(2) I, , do hereby certify that I am years of age, that I have read the petition in the above captioned matter and fully understand the contents thereof and do hereby, without reservation and without undue influence or coercion exerted upon me by any person, give my consent to the adoption of as prayed for in the foregoing petition. [In consenting to this adoption I am hereby retaining for myself all my rights and duties as a natural parent.]
I have read and understand the above and I am signing it as a free and voluntary act. In Witness Whereof, I have hereunto set my hand and seal this day of , 20 , at .
Date: ______ __________
(Signature of Consenter)Place of execution: __________
WITNESSES:
______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)______ ______ ______
(Name) (Signature) (Relationship to Consenter) (Date)ADDRESS __________
(street) (town) (state) (zip code)STATE OF ______
COUNTY OF ______
On this, the ____ day of ______ , 20 ____ , before me, ______ , the undersigned officer, personally appeared ______ , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_________________
(signature of notary public)
Title __________
My commission expires: __________
I maintain my office in __________(e) Petition for Involuntary Termination of Parental Rights: The petition for involuntary termination of parental rights provided for in 23 Pa.C.S.A. § 2512(b) and Pa.O.C. Rule 15.4(a) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
PETITION FOR INVOLUNTARY TERMINATION OF PARENTAL RIGHTS
23 Pa.C.S.A. § 2512(b) and Pa.O.C. Rule 15.4(a) To the Honorable, the Judges of said Court:
The petition of Franklin County Children and Youth Service respectfully represents:
1. That your petitioner, , [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania] [other relation to child], [having its office at ] [residing at ], Chambersburg, Franklin County, Pennsylvania, has the care and custody of , a minor male child born , , in County, Pennsylvania. was born to and .
2. That your petitioner, , is the [intermediary] [petitioner] in the above captioned adoption and files this petition under the provisions of Section 2504 of the Adoption Act of 1980, as amended.
3. That the mother of is , her address being , , Pennsylvania 17 ; she is years of age, having been born on , 19 , in , Pennsylvania; her race is ; she is currently married; she was not married at the time of the birth of the child and during one year prior thereto; and her religious affiliation is .
4. That is a [racial background] male child who is years old, having been born on , , in Franklin County, Pennsylvania. His religious affiliation is .
5. That the natural father of is , whose current address is , , Pennsylvania 17 ; he is years of age, his date of birth being , 19 ; his race is [racial background]; he is currently married; he was not married at the time of the birth of the child and during one year prior thereto; and his religious affiliation is .
6. The legal grounds for the involuntary termination of the parental rights of are as follows:
a) 23 Pa.C.S. § 2511 (a)(1)--The parent by conduct continuing for a period of at least six months immediately preceding the filing of the Petition either has evidenced a settled purpose of relinquishing parental claim to the child or has refused or failed to perform parental duties.
b) 23 Pa.C.S. § (a)(2)--The repeated and continued incapacity, abuse, neglect or refusal of the parent has caused the child to be without essential parental care, control or subsistence necessary for his physical or mental well-being and the conditions and causes of the incapacity, abuse, neglect or refusal cannot or will not be remedied by the parent.
c) 23 Pa.C.S. § (a)(3)--The parent is the presumptive but not the natural father of the child.
d) 23 Pa.C.S. § (a)(4)--The child is in the custody of an agency, having been found under such circumstances that the identity or whereabouts of the parent is unknown and cannot be ascertained by diligent search and the parent does not claim the child within three months after the child is found.
e) 23 Pa.C.S. § (a)(5)--The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency for a period of at least six months, the conditions which led to the removal or placement of the child continue to exist, the parent cannot or will not remedy those conditions within a reasonable period of time, the services or assistance reasonably available to the parent are not likely to remedy the conditions which led to the removal or placement of the child within a reasonable period of time and termination of the parental rights would best serve the needs and welfare of the child.
f) 23 Pa.C.S. § (a)(6)--In the case of a newborn child, the parent knows or has reason to know of the child's birth, does not reside with the child, has not married the child's other parent, has failed for a period of four months immediately preceding the filing of the petition to make reasonable efforts to maintain substantial and continuing contact with the child and has failed during the same four-month period to provide substantial financial support for the child.
g) 23 Pa.C.S. § (a)(7)--The parent is the father of a child who was conceived as a result of a rape or incest.
h) 23 Pa.C.S. § (a)(8)--The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency, 12 months or more have elapsed from the date of removal or placement, the conditions which led to the removal or placement of the child continue to exist and termination of parental rights would best serve the needs and welfare of the child.
7. The facts which support said grounds for termination are as follows:
a)
b)
c)
8. is not entitled to the benefits of the Soldiers and Sailors' Civil Relief Act of 1940, as amended. (50 U.S.C.A. 501 et seq.).
9. Petitioner(s) consents to accept custody of until such time as the child is adopted.
Wherefore, your petitioner prays your Honorable Court to enter an order directing that a time and place be set for a hearing on this Petition and upon holding said hearing to enter a Decree:
1. Finding that the involuntary termination of the parental rights of would best serve the needs and welfare of the child.
2. Directing the transfer of custody of to Petitioner(s).
3. Authorizing Petitioner(s) to give consent to the adoption of without further consent of, or notification to, .
And it will ever pray, etc.
Dated: ______ By, __________, Esquire
Attorney for Petitioner
, PA 17
(717) -
Attorney I.D. No.COMMONWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN, BEING DULY SWORN ACCORDING TO LAW, DEPOSES AND SAYS THE FACTS SET FORTH ABOVE ARE TRUE AND CORRECT TO THE BEST OF THE PETITIONER'S INFORMATION/KNOWLEDGE AND BELIEF.
_________________
SWORN AND SUBSCRIBED BEFORE ME
THIS ____ DAY OF ______ , 20 ____ ._________________
NOTARY PUBLIC
MY COMMISSION EXPIRES ______
I MAINTAIN AN OFFICE IN CHBG, PA(f) Confirmation of Consent. A petition for confirmation of consent under 23 Pa.C.S.A. § 2504(a) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
PETITION FOR CONFIRMATION OF CONSENT
23 Pa.C.S.A. § 2504(a) To the Honorable, the Judges of said Court:
The petition of , respectfully represents:
1. That your petitioner, , [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania] [relation to adoptee], [having its office at] [residing at] , County, Pennsylvania, has the care and custody of , a minor child born , in , County, Pennsylvania. The child was born to , Mother, and , Father.
2. That your petitioner, , is the [intermediary] [petitioner] in the above captioned adoption and files this petition under the provisions of Section 2504 of the Adoption Act of 1980, as amended.
3. The mother of , is , her address being , , Pennsylvania, ; she is years of age, having been born on , 19 , in , ; her race is , she is currently married, she was not married at the time of the birth of the child and during one year prior thereto, and her religious affiliation is .
4. The natural father of , is , whose current residence is , , Pennsylvania ; he is years of age; born on , 19 , in ; his race is , he is currently married, he was not married at the time of the birth of the child and during one year prior thereto, and his religious affiliation is .
5. has executed a consent for the subsequent adoption of , said consent being attached hereto and incorporated herein as ''Exhibit A.''
6. The aforesaid consent of was executed on , 200 and more than thirty (30) days have elapsed since the dates without the said filing or proceeding with a petition for the voluntary relinquishment of his/her parental rights.
7. consents to accept custody of .
8. Your petitioners seek to confirm the consent to adoption executed by the aforesaid pursuant to Section 2504 of the Adoption Act of 1980, as amended (23 Pa.C.S.A., Section 2504).
Wherefore, your petitioner prays your Honorable Court to make a decree confirming the consent to adoption executed by with respect to the minor child born to , on , 200 in , County, Pennsylvania, known as , thereby terminating all his rights and duties as father/mother of said and awarding custody of to [petitioner], under the provision of Section 2521 of the Adoption Code, and permitting the adoption of to proceed without further notice to or consent from .
And it will ever pray, etc.
Dated: ______ By, __________, Esquire
Attorney for Petitioner
, PA 17
(717) -
Attorney I.D. No.COMMONWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN, BEING DULY SWORN ACCORDING TO LAW, DEPOSES AND SAYS THE FACTS SET FORTH ABOVE ARE TRUE AND CORRECT TO THE BEST OF THE PETITIONER'S INFORMATION/KNOWLEDGE AND BELIEF.
_________________
SWORN AND SUBSCRIBED BEFORE ME
THIS ____ DAY OF ______ , 20 ____ ._________________
NOTARY PUBLIC
MY COMMISSION EXPIRES ______
I MAINTAIN AN OFFICE IN CHBG, PA(g) Order Scheduling Hearing. The orders scheduling the hearing on the Petition for Involuntary Termination of Parental Rights, the Petition for Adoption, and the Petition for Confirmation of Consent shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
ORDER
23 Pa.C.S.A. § 2504(b) And Now, this ____ day of ______ , 200 , the within Petition for Involuntary Termination of Parental Rights/Petition for Adoption/Petition to Confirm Consent having been presented in Chambers, read, considered and ordered filed, ______ , the ____ day of ______ , 200 , at ____ o'clock ____ m., prevailing time, in the assigned Court Room of the Franklin County Courthouse, Chambersburg, Franklin County, Pennsylvania, is fixed as the time and place of hearing thereon. Notice of the said hearing shall be given to ; , Esquire, Attorney for Natural Mother; ; , Esquire, Attorney for Natural Father; and , Esquire, Guardian Ad Litem for the above-referenced child.
By the Court.
_________________
J.(h) Notice of Confirmation Hearing: The notice of the hearing for Confirmation of Consent shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
NOTICE
23 Pa.C.S.A. § 2504(b) and 2513(b) TO: ,
A petition has been filed asking the court to put an end to all rights you have to your child, . The court has set a hearing to consider ending your rights to your child. That hearing will be held at Courtroom No. ____ , the Franklin County Courthouse, 157 Lincoln Way East, Chambersburg, Pennsylvania, on , , 200 at .m. Your presence is required at this hearing. You have a right to be represented at the hearing by a lawyer. You should take this paper to your lawyer at once. If you do not have a lawyer or cannot afford one, go to or telephone the office set forth below to find out where you can get legal help.
PENNSYLVANIA BAR ASSOCIATION
LAWYER REFERRAL SERVICE
P. O. BOX 186
HARRISBURG, PA 17108
TELEPHONE: (800) 692-7375 (PA ONLY) or
(717) 238-6807_________________
, Esquire
Attorney for Petitioner(i) Notice of Involuntary Termination Hearing: The notice of the hearing for Involuntary Termination of Parental Rights shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____ To:
NOTICE
23 Pa.C.S.A. § 2513(b) A petition has been filed asking the Court to put an end to all rights you have to your child, . The Court has set a hearing to consider ending your rights to your child. The hearing will be held in the Franklin County Court House, Chambersburg, Franklin County, Pennsylvania, on , the th day of , 200 at .m. If you do not appear at this hearing, the Court may decide that you are not interested in retaining your rights to your child, and your failure to appear may affect the Court's decision on whether to end your rights to your child. You are warned that even if you fail to appear at the scheduled hearing, the hearing will go on without you and the Court may end your rights to your child without you being present. You have a right to be represented at the hearing by a lawyer. You should take this paper to your lawyer at once. If you do not have a lawyer or cannot afford one, telephone the office set forth below to find out where you can get legal help.
PENNSYLVANIA BAR ASSOCIATION
LAWYER REFERRAL SERVICE
P. O. BOX 186
HARRISBURG, PA 17108
TELEPHONE: (800) 692-7375 (PA ONLY) or
(717) 238-6807The Court of Common Pleas of Franklin County is required by law to comply with the Americans With Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the Court, please contact the Office of the Court Administrator. All arrangements must be made at least 72 hours prior to a hearing or business before the Court. You must attend the scheduled hearing.
(j) Petition for Leave to Provide Notice by Publication: The Petition for Leave to Provide Notice by publication as per Pa.O.C. Rule 15.6 shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ D.O.B. : : Volume ____ , Page ____
PETITION FOR LEAVE TO PROVIDE NOTICE BY
PUBLICATION
Pa.O.C. Rule 15.6 To the Honorable, the Judges of said Court:
The petition of , respectfully represents:
1. That your petitioner, , [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania] [relation to adoptee], [having its office at ] [residing at ], Chambersburg, Franklin County, Pennsylvania, has the care and custody of , a minor child born , , in Franklin County, Pennsylvania. The child was born to , Mother, and , Father.
2. That your petitioner, , is the [intermediary] [petitioner] in the above captioned adoption and files this petition under the provisions of Section 2504 of the Adoption Act of 1980, as amended.
3. That the mother of is , her address being , , Pennsylvania, 17 ; she is years of age, having been born on , 19 , in , ; her race is , she is currently married, she was not married at the time of the birth of the child and during one year prior thereto, and her religious affiliation is .
4. That the natural father of is , whose current residence is , , Pennsylvania 17 ; he is years of age, having been born on , 19 , in ; his race is , he is currently married, he was not married at the time of the birth of the child and during one year prior thereto, and his religious affiliation is .
5. Petitioner has made the following efforts in an attempt to locate :
A) .
B) .
C) .
D) .
6. Despite the above mentioned diligent efforts to locate , Petitioner[s] [has] [have] been unable to ascertain their whereabouts.
Wherefore, your petitioner prays your Honorable Court to enter a decree granting leave to Petitioner[s] to provide notice to by Publication pursuant to Pennsylvania Rule of Orphan's Court 15.6(2).
And it will ever pray, etc.
FRANKLIN COUNTY CHILDREN
AND YOUTH SERVICEDated: ______ By, __________, Esquire
Attorney for Petitioner
, PA 17
(717) -
Supreme Ct. No.COMMONWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN, BEING DULY SWORN ACCORDING TO LAW, DEPOSES AND SAYS THE FACTS SET FORTH ABOVE ARE TRUE AND CORRECT TO THE BEST OF THE PETITIONER'S INFORMATION/KNOWLEDGE AND BELIEF.
_________________
SWORN AND SUBSCRIBED BEFORE ME
THIS ____ DAY OF ______ , 20 ____ ._________________
NOTARY PUBLIC
MY COMMISSION EXPIRES ______
I MAINTAIN AN OFFICE IN CHBG, PA(k) Order Authorizing Service by Publication: The Order authorizing service by publication as per Pa.O.C. Rule 15.6 shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
ORDER
Pa.O.C. Rule 15.6 And Now, this ____ day of ______ , 200 , the within Petition for Leave to Provide Notice by Publication having been presented in Chambers, read, considered and ordered filed, and ______ , the _____ day of ______ , 200 , at ____ o'clock ____ m., prevailing time, in the assigned Court Room of the Franklin County Courthouse, 157 Lincoln Way East, Chambersburg, Franklin County, Pennsylvania, having been fixed as the time and place of hearing thereon, Petitioner[s] [is] [are] hereby authorized to provide service to by publication in the Newspaper and County Legal Journal, pursuant to Pennsylvania Rule of Orphan's Court 15.6(2).
By the Court.
_________________
J.(l) Decree Involuntarily Terminating Natural Parent's Rights: The decree terminating the parental rights of a natural parents shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
DECREE
23 Pa.C.S.A. § 2513(d) and Pa.O.C. Rule 15.4(d) And Now, this th day of , 200 , the above named matter having been heard in a private hearing on , , 200 , at :00 .m, and it appearing to the Court that the facts set forth in the petition are true and correct, and that service of the notice of the foregoing private hearing, together with a copy of the Petition for Involuntary Termination of Parental Rights has been made upon , Natural Mother; , Esquire, Attorney for the Natural Mother; , Esquire, Attorney for the Natural Father; , Natural Father; and , Esquire, Guardian Ad Litem for the Child, in the manner required by this Court, and as evidenced by an Affidavit of Service filed in this matter by , Attorney for the petitioner, the Court makes the following findings of fact and conclusions of law:
FINDINGS OF FACT 1. That your petitioner, , [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania], (having its office) (residing at) at , , County, Pennsylvania, has the care and custody pursuant to an Order of Court dated, , 200 of [child's name], a minor (female)(male) child born , , in County, Pennsylvania. [Child's name] was born to [mother] and [father].
2. That [child] is a [racial background] male child who is ( ) years old, having been born on , , in County, Pennsylvania. Their religious affiliation is .
3. That the mother of is , her address being , , Pennsylvania 17 ; she is years of age, having been born on , 19 , in , Pennsylvania; her race is ; she is currently married; she was not married at the time of the birth of the child and during one year prior thereto; and her religious affiliation is .
4. That the natural father of is , whose current address is , , Pennsylvania 17 ; he is years of age, having been born on , 19 ; his race is ; he is currently married; he was not married at the time of the birth of the child and during one year prior thereto; and his religious affiliation is .
5. The legal grounds for the involuntary termination of the parental rights of are as follows:
b) 23 Pa.C.S. § 2511(a)(1)--The parent by conduct continuing for a period of at least six months immediately preceding the filing of the Petition either has evidenced a settled purpose of relinquishing parental claim to the child or has refused or failed to perform parental duties.
c) 23 Pa.C.S. § (a)(2)--The repeated and continued incapacity, abuse, neglect or refusal of the parent has caused the child to be without essential parental care, control or subsistence necessary for his physical or mental well-being and the conditions and causes of the incapacity, abuse, neglect or refusal cannot or will not be remedied by the parent.
d) 23 Pa.C.S. § (a)(3)--The parent is the presumptive but not the natural father of the child.
e) 23 Pa.C.S. § (a)(4)--The child is in the custody of an agency, having been found under such circumstances that the identity or whereabouts of the parent is unknown and cannot be ascertained by diligent search and the parent does not claim the child within three months after the child is found.
f) 23 Pa.C.S. § (a)(5)--The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency for a period of at least six months, the conditions which led to the removal or placement of the child continue to exist, the parent cannot or will not remedy those conditions within a reasonable period of time, the services or assistance reasonably available to the parent are not likely to remedy the conditions which led to the removal or placement of the child within a reasonable period of time and termination of the parental rights would best serve the needs and welfare of the child.
g) 23 Pa.C.S. § (a)(6)--In the case of a newborn child, the parent knows or has reason to know of the child's birth, does not reside with the child, has not married the child's other parent, has failed for a period of four months immediately preceding the filing of the petition to make reasonable efforts to maintain substantial and continuing contact with the child and has failed during the same four-month period to provide substantial financial support for the child.
h) 23 Pa.C.S. § (a)(7)--The parent is the father of a child who was conceived as a result of a rape or incest.
i) 23 Pa.C.S. § (a)(8)--The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency, 12 months or more have elapsed from the date of removal or placement, the conditions which led to the removal or placement of the child continue to exist and termination of parental rights would best serve the needs and welfare of the child
6. The facts that which support said grounds for termination are as follows:
a)
b)
c)
7. is not entitled to the benefits of the Soldiers and Sailors' Civil Relief Act of 1940, as amended. (50 U.S.C.A. 501 et seq.).
8. [Agency name][parent's name] consents to accept custody of until such time as the child is adopted.
CONCLUSIONS OF LAW 1. The Court has jurisdiction of the parties and the subject matter under 23 Pa.C.S.A. Section 2501 et seq.
2. The prayer of the petition should be granted, all requirements of the applicable statute having been complied with.
3. The Court finds by clear and convincing evidence the existence of valid grounds to involuntarily terminate the parental rights of pursuant to the following statutory authority:
(a) [TPR sections set forth above]
Now, Therefore, It Is Ordered And Decreed That:
(1) The parental rights and duties of the , Natural of , are hereby terminated, and
(2) Custody of , is awarded to [Agency][parent] under the provisions of Section 2521 of the Adoption Act, and
(3) is hereby advised pursuant to 23 Pa.C.S.A. § 2511 (c) of their continuing right to place and update personal and medical history information, whether or not the medical condition is in existence or discoverable at the time of the adoption, on file with the Court and with the Department of Public Welfare pursuant to 23 Pa.C.S.A. § 2905(d) and further is advised that they may, at the time of the termination of their parental rights or at any time thereafter, place on file with the Court or the Department of Health, a consent form asking for the Court or the Department to disclose the information contained in the child's original Certificate of Birth, or any other identifying or non-identifying information pertaining to him at any time after the child attains the age of 18, or if less than 18, to the child's adoptive parent or legal guardian pursuant to 23 Pa.C.S.A. § 2905(d).
(4) is hereby advised that they have the right to appeal this Order of Court within thirty days of its entry. Notice of such appeal shall be provided in accordance with the Pennsylvania Rules of Appellate Procedure.
(5) The Clerk of Orphan's Court is hereby directed to provide this Order to the following by First Class Mail and to note date of mailing in the adoption file.
a.
b.
c.
d.
By the Court,
_________________
J.(m) Decree Confirming Consent: The decree confirming a consent to adoption shall be substantially in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
DECREE OF COURT
23 Pa.C.S.A. § 2504(b) And Now, this th day of , 200 , the above named matter having been heard at a private hearing on , 200 , at :00 o'clock .m. and it appearing to the Court that: the facts set forth in the petition are true and correct, and that notice of the foregoing private hearing, held on , , 200 , at :00 o'clock .m., together with a copy of the petition for the Confirmation of Consent has been given to in the manner required by this Court; and , petitioner(s), has filed a petition and consented to accept custody of said child until such time as the child is adopted; and the prayer of the petition should be granted and all requirements of the applicable statutes have been complied with;
Now, Therefore, It Is Ordered And Decreed That:
1. The consent executed by is hereby confirmed;
2. The parental rights and duties of are hereby terminated;
3. Custody of is awarded to [petitioner], under the provisions of Section 2521 of the Adoption Act;
4. The adoption of may proceed without further notice to or consent from .
5. is hereby advised pursuant to 23 Pa.C.S.A. § 2511 (c) of his continuing right to place and update personal and medical history information, whether or not the medical condition is in existence or discoverable at the time of the adoption, on file with the Court and with the Department of Public Welfare pursuant to 23 Pa.C.S.A. § 2905(d) and further is advised that he may, at the time of the termination of their parental rights or at any time thereafter, place on file with the Court or the Department of Health, a consent form asking for the Court or the Department to disclose the information contained in the child's original Certificate of Birth, or any other identifying or non-identifying information pertaining to him at any time after the child attains the age of 18, or if less than 18, to the child's adoptive parent or legal guardian pursuant to 23 Pa.C.S.A. § 2905(d).
6. This Order shall be mailed by the Clerk of Orphan's Court by first class mail with date of mailing being documented to the following:
a)
b)
c)
By the Court,
_________________
J.(n) Report of Intention to Adopt: The report of intention to adopt described in 23 Pa.C.S.A. § 2531(b) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
REPORT OF INTENTION TO ADOPT
23 Pa.C.S.A. § 2531(b)
(To be filed by every person now having or hereafter receiving or retaining custody or physical care of any child, for the purpose or with the intention of adopting a child under the age of eighteen years within thirty days after the date of receipt of the custody or physical care of the child. No report shall be required when the child is the child, grandchild, stepchild, brother or sister of the whole or half blood, or niece or nephew by blood, marriage, or adoption, of the person receiving or retaining custody or physical care.)
Part A.
(To be completed by persons having or receiving a child from an agency.) 1. The name and Address of Agency is .
Part B.
(To be completed by persons having or receiving a child from an intermediary other than an agency.) 1. Child is , a [racial heritage] [male][female] child, who is years of age, having been born in , whose religious affiliation is .
2. The name and address of intermediary is .
Part C.
(To be completed by all persons required to file report.)
1. The circumstances surrounding the placement or receipt of physical care of the child are as follows:
A) Date of completion of pre-placement investigation (copy attached hereto):
B) Date when [I] [we] first applied to the agency was .
C) The reason this particular child was placed with [me] [us] is .
D) The length of time [I] [we] have known the child or about the child is .
E) [I] [We] [do] [do not] know the natural parents or their families.
F) The date the child was placed in [my] [our] home is .
2. A) There [was] [was not] any fee or expenses paid or to be paid to the intermediary or other persons.
B) If there was fees paid or to be paid above, the following is an itemized accounting of the moneys or other consideration paid or to be paid, and to whom:
$ to for .
to for .
3. A) To the best of [my] [our] knowledge and beliefs, the natural parents whose parental rights were terminated [have] [have not] received counseling.
B) If counseling has been received, it was received on [date] by [counselor] whose address is .
[I] [We] acknowledge that we have been advised or know that the natural parent(s) may revoke their consent to the adoption within thirty days of the date of execution of the consent. Signed this day of , 20 .
_________________ __________
Petitioner Petitioner
(o) Report of Intermediary: The report of intermediary required under 23 Pa.C.S.A. § 2533(b) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
REPORT OF INTERMEDIARY
23 Pa.C.S.A. § 2533(b)
(To be filed by intermediary who or which arranged the adoption placement of any child under the age of eighteen years within six months after filing a report of intention to adopt.) 2. The name and Address of Intermediary is .
3. Adoptee is , a [racial heritage] [male][female] child who is years of age, having been born on in , whose religious affiliation is .
4. Adoptee was placed with adopting parents on .
5. The Natural Mother of Adoptee is , a [racial heritage] female, who is years of age, having been born on in , she was [married][unmarried] at the time of adoptee's birth, and was [married][unmarried] within one year prior to adoptee's date of birth, and whose religious affiliation is .
6. The Natural Father of Adoptee is , a [racial heritage] male, who is years of age, having been born on in , he was [married][unmarried] at the time of adoptee's birth, and was [married][unmarried] within one year prior to adoptee's date of birth, and whose religious affiliation is .
7. Parental rights were terminated by [identify court] by decree dated , docketed to and custody was awarded to .
8. A) To the best of [my][our] knowledge and beliefs, the natural parents whose parental rights were terminated [have][have not] received counseling.
B) If counseling has been received, it was received on [date] by [counselor] whose address is .
C) If no decree of termination and/or relinquishment was entered, the residence and mailing addresses of the natural parent(s) [is][are]:
Mother:
Father:9. A) The exhibits required by Section 2534 of the Adoption Act are attached.
B) Consents required by Section 2711 of the Adoption Act are attached as exhibits.
C) Consents are not required under Sections 2713, 2714 and 2711 of the Adoption Act because .
10. [No][The following] moneys or consideration has been or will be paid or received by the Intermediary or to or by any other person or persons to the knowledge of the Intermediary by reason of the adoption placement.
$ to for .
10. The child owns or possesses the following described and valued property: .
11. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of Adoptee.
12. [If applicable] A birth certificate or registration of birth cannot be obtained for the following reasons: .
13. Written notice of the filing of this Report and the date of the same will be given to the adopting parent(s) forthwith.
14. Medical information as defined in Section 2102 of the adoption Act was obtained, and if not obtained the reason therefore is .
Signed this day of , 20 .
_________________
Signature of Intermediary or Authorized Officer
COMMONWEALTH OF PENNA. : : ss. COUNTY OF (FRANKLIN)(FULTON) : Personally appeared before me a notary public in and for said County, , Affiant herein, who being duly sworn/affirmed according to law, deposes and says that the facts set forth in the foregoing are true.
_________________
Sworn/affirmed and subscribed to before me this
_________________
(SEAL)
My commission expires ______
I maintain my office ______
County, Pennsylvania(p) Petition for Adoption: The petition for adoption in 23 Pa.C.S.A. § 2701 and Pa.O.C. Rule 15.5 shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
PETITION FOR ADOPTION
23 Pa.C.S.A. § 2701 and Pa.O.C. Rule 15.5 To The Honorable, The Judges of Said Court:
The petition of ______ respectfully represents:
I. Your petitioner(s) (is) (are):
A. residing at (residence and mailing address) who is (married) (single) and years of age, having been born on and whose occupation is , religious affiliation is , racial background is and relationship to the proposed adoptee is ;
B. residing at (residence and mailing address) who is (married) (single) and years of age, having been born on and whose occupation is , religious affiliation is , racial background is and relationship to the proposed adoptee is ;
II. A. The report of Intention to Adopt under Section 2533 (has) (has not) been filed.
B. The report of the intermediary under Section 2533 (has) (has not) been filed; however, in lieu thereof, Exhibit A is attached hereto.
III. The name and address of the intermediary is:
IV. Your petitioner(s) desire(s) to adopt who was born on and who has resided with your petitioner(s) since as one of (her)(his)(their) heirs and declare(s) that (she)(he)(they) will perform all of the duties of parent(s) to said adoptee.
V. A. Exhibits required by Section 2702 of the Adoption Act are attached.
B. Consents required by Section 2711 of the Adoption Act are attached as exhibits.
C. Consents are not required under 2713, 2714 and 2711 of the Adoption Act by reason of (state facts):
D. Exhibit containing vital statistics is attached as Exhibit .
VI. (Strike out if not applicable) A birth certificate or certificate of registration of birth cannot be obtained for the adoptee and the petitioner would request that the Court establish a time and place of birth for said adoptee at the adoption hearing on the basis of the evidence presented. (Set forth reasons for failure to obtain a birth certificate or certificate of registration of birth and the efforts made to so obtain those documents):
VII. That your petitioner(s) believing that the welfare of said adoptee will be promoted by said adoption, desire(s) that the relationship of parent and child be established between (names of petitioners) and the adoptee, and the adoptee shall be known as (new full name of child); and (she)(he)(they) respectfully pray(s) that the Court make a decree in accordance with this prayer.
_________________
- Petitioner_________________
- Petitioner
COMMONWEALTH OF PENNA. : : ss. COUNTY OF (FRANKLIN)(FULTON) : Personally appeared before me a notary public in and for said County, (name of petitioners), petitioner(s) herein, who being duly sworn/affirmed according to law, depose(s) and say(s) that the facts set forth in the foregoing are true.
_________________
_________________
Sworn/affirmed and subscribed to before me this
_________________
(SEAL)
My commission expires ______
I maintain my office ______
County, Pennsylvania(q) Exhibit ''A'': Exhibit ''A'' of the adoption petition in (p) above shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
EXHIBIT A 1. Name and Address of Intermediary:
2. Adoptee, , is years of age, having been born on , in , Pennsylvania, whose racial background is , and religious affiliation is .
3. Adoptee was placed with adopting parent(s) on .
4. The natural parent(s) of adoptee is/are:
a. Mother: [name], is years of age, having been born on , in , Pennsylvania; their racial background is ; they were [married][single] at the time of the adoptee's birth and were [married][single] within one year prior to the birth of Adoptee; and their religious affiliation is .
b. Father: [name], is years of age, having been born on , in , Pennsylvania; their racial background in ; they were [married][single] at the time of the Adoptee's birth and were [married][single] within one year prior to the birth of the Adoptee; and their religious affiliation is .
5. A. Parental rights and duties were terminated and/or relinquished by [Court where terminated] by decree dated , docketed to , and custody was awarded to .
B. If no decree of termination or relinquishment has been entered, the residence and mailing addresses of the natural parent(s) [is][are]:
1) Mother:
2) Father:
6. A. Exhibits required by Section 2543 of the adoption act are attached.
B. Consents required by section 2711 of the Adoption Act are attached as exhibits.
C. Consent are not required under sections 2713, 2714, and 2711 of the Adoption Act for the following reasons: .
7. [No][The following] moneys or consideration have been or will be paid or received by the intermediary or to or by any other person or persons to the knowledge of the intermediary by reason of the adoption placement.
a)
b)
8. State value and describe all property owned or possessed by Adoptee:
9. No provisions of any act regulating interstate placement of children have been violated with respect to the placement of the Adoptee.
10. [Strike if not applicable] A birth certificate or registration of birth cannot be obtained for the following reasons:
11. Written notice of the filing of this report and the date of the same will be given to the adopting parent(s) forthwith.
12. Medical history information as defined in section 2102 of the Adoption Act was obtained, and if not obtained, the reason therefore is as follows:
Signed this day of , 20 .
_________________ __________Petitioner Petitioner
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN, BEING DULY SWORN ACCORDING TO LAW, DEPOSES AND SAYS THE FACTS SET FORTH ABOVE ARE TRUE AND CORRECT TO THE BEST OF THE PETITIONER'S INFORMATION/KNOWLEDGE AND BELIEF.
_________________ __________SWORN AND SUBSCRIBED BEFORE ME
THIS ____ DAY OF ______ , 20 ____ ._________________
NOTARY PUBLIC
MY COMMISSION EXPIRES ______
I MAINTAIN AN OFFICE IN CHBG, PA(r) Vital Statistics Exhibit: The vital statistics exhibit of the adoption petition in (p) above shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
ADOPTION VITAL STATISTICS EXHIBIT 1. Adoptee, is a [male][female], who is years of age, having been born on in , County, , United States.
2. The new name proposed for Adoptee is .
3. The Adoptive Father's full name is ; he is [racial heritage]; his age at the time of birth of Adoptee was , having been born on , in ; and his usual occupation is , the industry or business being .
4. The Adoptive Mother's full maiden name is ; she is [racial heritage]; her age at the time of birth of Adoptee was , having been born on , in ; and her usual occupation is , the industry or business being .
5. The Adoptive Parents mailing address at the time of the adoption is .
6. The attorney handling the adoption is , Esquire, whose mailing address is .
(s) Disclosure of Fees: The disclosure of fees statement as required in 23 Pa.C.S.A. §§ 2533(b)(8) and 2724(a) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
DISCLOSURE OF FEES AND COSTS
23 Pa.C.S.A. §§ 2533(b)(8) and 2724(a) $ Clerk of Courts, Filing fees
Notary Fees
Attorney Fees
Vital Statistics, birth certificate
Home Study
Agency Fees
Doctor Fees (Mother)
Doctor Fees (Baby)
Hospital Fees (Mother)
Hospital Fees (Baby)
Prescription Medications
Other-_____
$ Total[I][We] certify that the above itemization of fees and costs paid by , in connection with the above captioned adoption is accurate and complete to the best of my knowledge, information and belief. Signed this day of , 20 .
_________________ __________
Petitioner Petitioner
(t) Adoption Decree: The adoption decree as required in 23 Pa.C.S.A. § 2902 shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
DECREE
23 Pa.C.S.A. § 2902 And Now, this day of , 200 , it appearing that the statements set forth in the Petition for Adoption filed and docketed in this matter are true, and that the welfare of the person proposed to be adopted will be promoted by such adoption, and that all requirements of the adoption law of Pennsylvania have been complied with,
It Is Hereby Ordered And Decreed that the adoption is granted and that the person proposed to be adopted by the petitioners, and , shall have all the rights of a child and heir of said petitioners, and shall be subject to the duties of such child, and henceforth shall be known as .
By the Court,
_________________
J.
COMMONWEALTH OF PENNA. : : ss. COUNTY OF (FRANKLIN)(FULTON) : I, ______ , Clerk of Orphans' Court Division of the Court of Common Pleas of the 39th Judicial District, Pennsylvania, (Franklin)(Fulton) County Branch, do hereby certify that the foregoing is a full, true and correct copy of a Decree of Adoption by the petitioners therein named as the same remains on file and of record in this office.
In Testimony Whereof, I have hereunto set
My hand and affixed the seal of __________
The said office this ____ day of ______ , 200 ____ .
Clerk, Orphans' Court Division,
Court of Common Pleas of the 39th Judicial District,
Pennsylvania, (Franklin)(Fulton) County Branch
(u) Acceptance of Service: The acceptance of service as described in 23 Pa.C.S.A. §§ 2503(a), 2513(b), 2721; Pa.O.C. Rule 15.6; Pa.R.C.P. 402(b) shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
ACCEPTANCE OF SERVICE
23 Pa.C.S.A. §§ 2503(a), 2513(b), 2721; Pa.O.C.
Rule 15.6; Pa.R.C.P. 402(b)I, , Esquire, counsel for , certify that I am authorized to accept service on behalf of and hereby accept service of the Petition to Involuntarily Terminate Parental Rights/Petition for Confirmation of Consent/Petition for Termination of Parental Rights/Adoption Petition and the Order scheduling a hearing in the above-captioned matter.
_________________
Date(v) Affidavit of Service: The affidavit of service shall be in substantially the following form:
IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT OF PENNSYLVANIA--FRANKLIN COUNTY BRANCH
IN RE: ADOPTION OF : Orphans' Court Division : : Adoption Docket ______ Born : : Volume ____ , Page ____
AFFIDAVIT OF SERVICE
STATE OF PENNSYLVANIA : : ss. COUNTY OF FRANKLIN : , Esquire, being duly sworn according to law, deposes and says that he/she served copies of the attached Notice of Hearing, together with copies of the petitions filed in this matter, on the following:
(1) , Esquire, Guardian ad Litem for the child(ren), at , , Pennsylvania, 17 on , 200 by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned;
(2) , Esquire, Attorney for Natural Mother, , at , Pennsylvania 17 on , 200 as evidenced by an Acceptance of Service;
(3) , Natural Mother, at , , Pennsylvania, 17 on , 200 by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned; and
(4) , Natural Father, at , , Pennsylvania 17 on , 200 by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned.
Sworn and subscribed to
before me, this th day of
, 200 .______ __________
Notary Public , Esquire--Attorney for Petitioner
[Pa.B. Doc. No. 08-172. Filed for public inspection February 1, 2008, 9:00 a.m.]
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