[46 Pa.B. 4078]
[Saturday, July 30, 2016]
[Continued from previous Web Page]
Appendix L: Petition and Orders for Electroconvulsive Therapy for a Person under Civil Commitment
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
IN RE: ) ) ) No. ____ of ______ _________________ *10 ) an alleged incapacitated person.
PETITION FOR ORDER OF COURT AUTHORIZING ELECTRO-CONVULSIVE THERAPY AS REQUIRED BY 55 PA. CODE § 5100.54, ARTICLE VI 2(b) (4) Your Petitioner, * ______ , pursuant to 50 Pa. §§ 7102, 7104, and 7305, and 55 Pa. Code § 5100.54, Article VI, 2 (b), hereby requests that this Court issue an Order authorizing electro-convulsive therapy for the Respondent, * ______ and in support of such request, avers and represents as follows:
1. * ______ , is a * ______ year old patient at * ______ , having been admitted to * ______ on * ______ Under an involuntary commitment order issued pursuant to Section * ______ of the Mental Health Procedures Act (50 P.S. §* ______).
2. By Order of Court dated * ______ , the Respondent * ______ was found to be * ______ , and was committed or recommitted to * ______ for involuntary in-patient care, for a period not to exceed * ______ days, pursuant to Section ______ of the Mental Health Procedures Act (50 P.S. §* ______). See Commitment Order and underlying Commitment Petition, attached as Exhibit 1.
3. * ______'s domicile prior to admission to * ______ was * ______ .
4. * ______ carries a diagnosis of * ______ which has been poorly responsive to treatment.
5. Over the last * ______ , * ______ has had a number of treatment regimens of * ______ which have failed to significantly improve *his/her symptoms.
6. * ______'s recent symptoms have included refusing to * ______ .
7. ______'s treatment team has recommended electro-convulsive therapy (ECT) to treat *his/her psychiatric condition, and it has been documented in *his/her record that all reasonable and less intensive treatment modalities have been considered, and that ECT represents the most effective therapy for * ______ at this time.
8. * ______ , M.D., * ______'s treating psychiatrist who has experience and training related to ECT, has evaluated * ______ and has recommended ECT for * ______ . See Notarized Statement by Doctor * ______ , attached as Exhibit 2.
9. Attempts have been made to give *______ a full explanation of the anticipated nature and duration of the ECT, and why the treating psychiatrist is recommending ECT.
10. * ______ has been told that *he/she has the right to accept or refuse ECT, and that if *he/she consents, *he/she has the right to revoke *his/her consent for any reason at any time prior to or between treatments.
11. * ______ has, to date, been unwilling and/or unable to discuss the recommended ECT treatment with Doctor * ______ or other * ______ clinical personnel, and has neither consented to or refused the recommended ECT.
12. Because of *his/her psychiatric condition, * ______ clinical personnel believes that Respondent, * ______ lacks the capacity to provide informed consent to the recommended medical treatment - i.e. ECT.
13. It is recommended by * ______ that the ECT be begun as soon as possible; the ECT would be performed at * ______ .
14. Prior to initiating ECT for * ______ , * ______ , in accordance with standard procedure, would evaluate * ______ , and would make an independent medical determination of the need for and duration of ECT. See Exhibit 2.
15. This Petition is brought pursuant to 55 Pa. Code § 5100.54, Article VI (2)(4), which provides that when a patient's psychiatrist determines that the patient could benefit from ECT, but also believes that the patient does not have the capacity to give informed consent to ECT, a Court order authorizing ECT must be obtained before ECT can be administered to the patient.
WHEREFORE, your Petitioner prays that this Court issue an Order authorizing the administration of ECT to the Respondent, * ______ .
Respectfully submitted,
By _________________
Counsel for PetitionerDated: _________________
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
IN RE: * , ) Respondent ) No. )
PRELIMINARY ORDER OF COURT NOW, this ____ day of ______ , the foregoing Petition having been presented, upon consideration thereof and on motion of counsel for the Petitioner, it is ORDERED and DECREED that a hearing be held to consider the Petitioner's request. The time and place of hearing on this Petition are fixed for the ____ day of ______ , beginning at ____ o'clock, __.M., prevailing time, in the Orphans' Court Division, 17th Floor, Frick Building, 437 Grant Street, Pittsburgh, Pennsylvania 15219.
The Respondent shall be given notice of the hearing on this Petition by serving *him/her personally with this Preliminary Order of Court and a copy of the foregoing Petition prior to the time of the hearing.
BY THE COURT:
_________________ J.
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
IN RE: * _________________ , ) Respondent ) No. )
ORDER OF COURT AUTHORIZING ELECTRO-CONVULSIVE THERAPY NOW, this ____ day of ______ , this Court having reviewed and considered the Respondent's current mental condition, the treatment that has been provided to Respondent to date and the results of such treatment, and the recommendation by &his/her treatment team and treating psychiatrist for electro-convulsive therapy, and having found that Respondent, due to a psychiatric condition which significantly impairs *his/her capacity to receive information effectively and to make and communicate decisions concerning *his/her medical and psychiatric treatment is unable to make or communicate an informed decision regarding treatment by electro-convulsive therapy, this Court, in accordance with 55 Pa. Code § 5100.54, Article VI 2(b)(4), hereby authorized ______ to provide electro-convulsive therapy to Respondent, in accordance with their medical judgment, for a period not to exceed days from the date of this Order.
BY THE COURT:
_________________ J.
CHAPTER XV. ADOPTIONS
ORPHANS COURT DIVISION RULE 15 Rule 15. Adoption.
Sec. 1. Venue.
A proceeding for voluntary relinquishment, involuntary termination of parental rights, confirm consent to adoption, or adoption may be brought in the County of Allegheny if the parent or parents or the adoptee or person or persons who have filed a report of intent to adopt, reside in Allegheny County, or if an office of an agency having custody of or having placed the adoptee is located therein. Such a proceeding may also be brought with leave of Court in Allegheny County if the adoptee formerly resides in Allegheny County.
Sec. 2. Parties.
Any individual may be adopted, regardless of his age or residence. Any individual may become an adopting parent. Parent includes adoptive parent.
Sec. 3. Voluntary Relinquishment. Relinquishment to Agency.
Petition.
(a) A petition of a parent or parents for permission to relinquish forever all parental rights and duties with respect to a child under the age of eighteen years who has been in the care of an agency for a minimum period of three (3) days, or, whether or not the agency has the physical care of the child, the agency has received a written notice of the present intent to transfer to it custody of the child, executed by the parent, shall contain the following information:
(1) The name and address of petitioner and identity, i.e., parent.
(2) The name, address, age, racial background and religious affiliation of the parent or parents, and all alleged parents and any deceased parent.
(3) The marital status of the mother as of the time of birth of the child and during one (1) year prior thereto, and, if the mother has ever been married, the name of her husband or husbands, and her maiden name and how prior marriages were terminated;
(4) The name, age, date of birth, racial background, sex and religious affiliation of the child; the name of the child shall include all names by which child has been identified on the birth certificate and any other legal document;
(5) The name and address of the agency having care of the child;
(6) The date when the child was placed with the agency;
(7) When the child is born out of wedlock, whether the mother and father of the child intend to marry;
(8) If the mother of the child was married within one (1) year prior to the birth of the child but identifies the natural father as a person other than her spouse, then the information as to the spouse (legal father) of the mother shall be set forth as required in subparagraph (2);
(9) The date on which the parent has executed a written notice of the present intent to transfer to the agency custody of the child, if said notice was executed;
(10) The reasons for seeking relinquishment.
(11) If Petitioner also seeks to terminate the parental rights of the putative father, then state whether or not the putative father has filed a petition to Voluntarily Relinquish his parental rights pursuant to 23 Pa.C.S.A. Section 2501 and 2503 and whether the putative father has filed an Acknowledgment of Paternity or Claim of Paternity pursuant to 23 Pa.C.S.A. Section 8302 or 8303.
The prayer shall be for permission to relinquish forever all parental rights and duties of the Petitioner with respect to the child and to award to the agency the custody of the child. The prayer may also be for permission to terminate the parental rights of the putative father pursuant to 23 Pa.C.S.A. Section 2503(d).
(b) Exhibits.
The petition shall have attached to it the following exhibits:
(1) An original or certified birth certificate or certification of registration of birth of the child;
(2) The written notice executed by the Petitioner to the agency of that parent's present intent to transfer to the agency custody of the child, if applicable;
(3) The joinder of the agency having care of the child and the consent to the agency to accept custody of the child until such time as the child is adopted.
(4) Original or certified copy of any previous divorce decrees relating to the mother and original or certified copy of mother's previous election to resume maiden name, if applicable;
(5) Original or certified copy of documentation from appropriate State Agency certifying Acknowledgement of Paternity or Claim of Paternity indicating that no acknowledgement of paternity or claim of paternity has been filed.
(c) Preliminary Decree and Hearing.
Upon presentation of the petition, the Court, by preliminary decree, shall fix a time for hearing which shall be not less than ten days after filing of the petition. Notice shall be given to the Petitioner. Notice of the hearing shall also be given to the other parent including any alleged natural father, to the putative father whose parental rights could be terminated pursuant to 23 Pa.C.S.A. Section 2503(d), and to the legal father (spouse of mother within during one (1) year prior to birth, if he is not identified as the natural father, and to the parents or guardians of a Petitioner who has not reached the age of 18 years. The Petitioner and an authorized representative of the agency (if agency is involved) shall be examined under oath at the hearing. The hearing shall be in private. The notices shall be in substantially the following forms, and Affidavit/Proof of Service of the required notices of hearing shall be filed with the Court at least five (5) days prior to the scheduled hearing.
(1) Notice to Petitioner of Hearing on Petition for Voluntary Relinquishment.
(Caption of Case) TO: ______ (name of petitioner) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS YOU HAVE TO YOUR CHILD, (insert name of child). THE COURT HAS SET A HEARING TO CONSIDER ENDING YOUR RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. YOUR PRESENCE IS REQUIRED AT THE 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.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(2) Notice to the Other Parent and Legal Father.
(Caption of Case) TO: ______ (other parent and/or legal father) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED BY (petitioner's name) ASKING THE COURT TO PUT AN END TO ALL RIGHTS SHE/HE HAS TO YOUR CHILD, (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. A COPY OF THE NOTICE TO PETITIONER IS ATTACHED.
_________________
Name of Attorney
Address
Telephone Number(3) Notice to Putative Father whose rights may be terminated.
(Caption of Case) TO: ______ (name of putative father) _________________
FATHER OF ______(adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED BY (petitioner's name) ASKING THE COURT TO PUT AN END TO ALL RIGHTS SHE HAS TO YOUR CHILD, (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. A COPY OF THE NOTICE TO PETITIONER IS ATTACHED.
YOUR RIGHTS TO (adoptee's name) MAY ALSO BE TERMINATED IF YOU FAIL TO FILE EITHER AN ACKNOWLEDGEMENT OF PATERNITY OR CLAIM OF PATERNITY PURSUANT TO 23 Pa.C.S.A. SECTION 5103 AND YOU FAIL TO EITHER APPEAR AT THIS HEARING FOR THE PURPOSE OF OBJECTING TO THE TERMINATION OF YOUR RIGHTS TO (adoptee's name) OR YOU FAIL TO FILE A WRITTEN OBJECTION TO THE TERMINATION OF YOUR RIGHTS WITH THE COURT PRIOR TO 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.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(4) Notice to Parent(s) or Guardian of Petitioner who has not reached the age of 18 years.
(Caption of Case) TO: ______ MOTHER/FATHER OF ______ , MINOR NATURAL FATHER/MOTHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (name of minor natural parent) ______ HAS TO HIS/HER CHILD, ______ (adoptee's name) ______ . THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO HIS/HER CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. A COPY OF THE NOTICE TO PETITIONER IS ATTACHED.
_________________
Name of Attorney
Address
Telephone Number(d) Final Decree. (1) A decree of termination in substantially the following form shall be submitted to the Court at the hearing:
And now, this ____ day of ______ , the foregoing Petition For Voluntary Relinquishment of Parental Rights and duties to an Agency having been heard, upon consideration thereof and of the supporting testimony and it appearing that ______ desires to relinquish forever all parental rights with respect to ______ , the Court finds the averments of facts in said petition are true and that the prayer of the petition should be granted;
Now, therefore it is ordered, adjudged and decreed that all parental rights and duties of with respect to said child are hereby terminated in accordance with The Adoption Act, 23 Pa.C.S.A. Section 2501 and 2503; said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings; and that custody of ______ is hereby awarded to ______ .
_________________ , J.
(2) If the rights of the putative father will also be terminated pursuant to 23 Pa.C.S.A. Section 2503(d) then a decree in substantially the following form shall be submitted to the Court at the hearing:
And now, this ____ day of ______ , the foregoing Petition For Voluntary Relinquishment of Parental Rights and duties to an Agency having been heard, upon consideration thereof and of the supporting testimony and it appearing that ______ desires to relinquish forever all parental rights with respect to ______ , the Court finds the averments of facts in said petition are true and that the prayer of the petition should be granted;
Now, therefore it is ordered, adjudged and decreed that all parental rights and duties of with respect to said child are hereby terminated in accordance with The Adoption Act, 23 Pa.C.S.A. Section 2501 and 2503; said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings;
Furthermore, the Court finds that the putative father, ______ will not file a Petition to voluntarily relinquish his parental rights pursuant to The Adoption Act, 23 Pa.C.S.A. Section 2501 and 2503, he has not filed an Acknowledgement of Paternity or Claim of Paternity pursuant to 23 Pa.C.S.A. Section 5103, he has not appeared to object to the termination of his parental rights to said child, and has not filed a written objection with this Court to the termination of his parental rights to said child;
Now, therefore it is ordered, adjudged and decreed that the parental rights of the putative father ______ with respect to said child are hereby terminated in accordance with 23 Pa.C.S.A. Section 2503(d); said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings;
It is further ordered and decreed that custody of ______ is hereby awarded to ______ .
_________________ , J.
(e) Right to file personal information. At the time the decree of termination is transmitted to the parents whose rights are terminated, the Court shall advise that parent in writing of his or her right to place personal information on file with the Court and with the Department of Health pursuant to 23 Pa.C.S.A. Section 2905(d) (relating to impounding of proceedings and access to records).
Sec. 4 Relinquishment to Adult Intending to Adopt Child.
Petition.
(a) A petition of a parent for permission to relinquish forever all parental rights with respect to a child under the age of eighteen years who has been in the exclusive care of an adult or adults for minimum period of thirty days, and who have filed a Report of Intention to Adopt as required by the Adoption Act, 23 Pa.C.S.A. Section 2531 shall contain the following information:
(1) The name and address of the Petitioner and identity, i.e., parent;
(2) The name, address, age, racial background, and religious affiliation of the parent or parents; and all alleged parents and any deceased parent;
(3) The marital status of the mother as of the time of the birth of the child and during one (1) year prior thereto, and if the mother has ever been married, the name of her husband or husband's and/or maiden name and how prior marriages were terminated;
(4) The name, age, date of birth, racial background, sex and religious affiliation of child; the name of the child shall include all names by which child has been identified on the birth certificate and any other legal document;
(5) The date when the Report of Intention to Adopt was filed;
(6) The date when the child was placed with the adult or adults intending to adopt;
(7) When the child is born out of wedlock, whether the mother and father of the child intend to marry;
(8) If the child is born out of wedlock and the father has been identified, information as to the father shall be set forth as required in subparagraph (2);
(9) If the mother of the child was married within one (1) year prior to the birth of the child but identified the natural father as a person other than this spouse, then the information as to the spouse (legal father) of the mother shall be set forth as required in subparagraph (2);
(10) If the natural father is unknown, whether there has been any claim of paternity pursuant to 23 Pa.C.S.A. Section 5103.
(11) The reasons for seeking relinquishment.
(12) If Petitioner also seeks to terminate the parental rights of the putative father, then state whether or not the putative father has filed a Petition to Voluntarily Relinquish his parental rights pursuant to 23 Pa.C.S.A. Section 2502 and 2503 and whether the putative father has filed an Acknowledgement of Paternity or Claim of Paternity pursuant to 23 Pa.C.S.A. Section 5103.
The prayer shall be for permission to relinquish forever all parental rights to the child and to award to the adult or adults intending to adopt, custody of the child. The prayer may also be for permission to terminate the parental rights of the putative father of the child pursuant to the 23 Pa.C.S.A. Section 2503(d).
(b) Exhibits. The petition shall have attached to it the following
(1) An original or certified birth certificate or certification of registration of birth of the child;
(2) The separate consent of the adult or adults intending to adopt, to accept custody of the child;
(3) Original or certified copy of any previous divorce decrees relating to the mother and original or certified copy of any previous elections to resume maiden name relating to the mother;
(4) Original or certified copy of Acknowledgement of Paternity or Claim of Paternity indicating that no acknowledgement of paternity or claim of paternity has been filed.
(c) Preliminary Decree and Hearing. Upon presentation of the petition the Court, by preliminary decree, shall fix a time for hearing which shall be not less than ten (10) days after filing of the petition. Notice of the hearing shall be given to the Petitioner. Notice of the hearing shall also be given to the other parent, to the putative father whose parental rights could be terminated pursuant to 23 Pa.C.S.A. Section 2503(d), to the legal father (spouse of mother within one year prior to birth), if he is not identified as the natural father, and to the parents or guardians of a Petitioner who has reached the age of 18. The Petitioner and an authorized representative from the agency (if agency is involved), shall be examined under oath at the hearing, the hearing shall be in private. The notices shall be in substantially the following forms and Affidavit/Proof of Service of the required notices of hearing shall be filed with the Court at least five (5) days prior to the scheduled hearing.
(1) Notice to Petitioner of Hearing on Petition for Voluntary Relinquishment.
(Caption of Case) TO: ______ (name of Petitioner) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS YOU HAVE TO YOUR CHILD, (insert name of child). THE COURT HAS SET A HEARING TO CONSIDER ENDING YOUR RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. YOUR PRESENCE IS REQUIRED AT THE 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.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(2) Notice to the Other Parent and Legal Father.
(Caption of Case) TO: ______ (name of Petitioner) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED BY (Petitioner's name) ASKING THE COURT TO PUT AN END TO ALL RIGHTS SHE HAS TO YOUR CHILD, (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M., A COPY OF THE NOTICE TO PETITIONER IS ATTACHED.
_________________
Name of Attorney
Address
Telephone Number(3) Notice to Putative Father whose rights may be terminated.
(Caption of Case) TO: ______ (putative father) _________________
FATHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED BY (Petitioner's name) ASKING THE COURT TO PUT AN END TO ALL RIGHTS SHE HAS TO YOUR CHILD, (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , at __M. A COPY OF THE NOTICE TO PETITIONER IS ATTACHED.
YOUR RIGHTS TO (adoptee's name) MAY ALSO BE TERMINATED IF YOU FAIL TO FILE EITHER AN ACKNOWLEDGEMENT OF PATERNITY OR CLAIM OF PATERNITY PURSUANT TO 23 Pa.C.S.A. SECTION 5103 AND YOU FAIL TO EITHER APPEAR AT THIS HEARING FOR THE PURPOSE OF OBJECTING TO THE TERMINATION OF YOUR RIGHTS TO (adoptee's name) OR YOU FAIL TO FILE A WRITTEN OBJECTION TO THE TERMINATION OF YOUR RIGHTS WITH THE COURT PRIOR TO 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.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(4) Notice to Parent(s) or Guardian of Petitioner who has not reached the age of 18 years.
(Caption of Case) TO: ______ MINOR NATURAL MOTHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (name of minor natural parent) ______ HAS TO HIS/HER CHILD ______ (adoptee's name) ______ . THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO HIS/HER CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __M. A COPY THE NOTICE TO PETITIONER IS ATTACHED.
_________________
Name of Attorney
Address
Telephone Number(d) Final Decree.
(1) A decree of termination in substantially the following form shall be submitted to the Court at the Hearing:
And now, this ____ day of ______ , the foregoing Petition for Voluntary Relinquishment of Parental Rights to an adult(s) intending to Adopt Child having come on to be heard, upon consideration thereof and of the supporting testimony and it appearing that , desires to relinquish forever all parental rights with respect to , the Court finds the averments of facts in said petition are true and that the prayer of the petition should be granted;
Now, therefore, it is ordered, adjudged and decreed that the parental RIGHTS OF THE ______ with respect to said child are hereby terminated in accordance with 23 Pa.C.S.A. Section 2502 and 2503; said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings; and that custody of ______ is hereby awarded to ______ .
_________________ , J.
(2) If the rights of the putative father will also be terminated pursuant to 23 Pa.C.S.A. Section 2503(d), then a decree in substantially the following form shall be submitted to the Court at the hearing:
And now, this ____ day of ______ , the foregoing Petition for Voluntary Relinquishment of Parental Rights to an Adult(s) intending to Adopt Child having come on to be heard, upon consideration thereof and of the supporting testimony and it appearing that ______ , desires to relinquish forever all parental rights with respect to ______ , the Court finds the averments of facts in said petition are true and that the prayer of the petition should be granted;
Now, therefore, it is ordered, adjudged and decreed that the parental rights of ______ with respect to said child are hereby terminated in accordance with 23 PA C.S.A. Section 2502 and 2503; said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings;
Furthermore, the Court finds that the putative father ______ will not file a Petition to voluntarily relinquish his parental rights pursuant to 23 Pa.C.S.A. Section 2502 or 2503 of the Adoption Act, he has not filed an Acknowledgement of Paternity or Claim of Paternity pursuant to 23 Pa.C.S.A. Section 5103, he has not appeared to object to the termination of his parental right to said child, and has not filed a written objection with this Court to the termination of his parental rights to said child;
Now, therefore, it is ordered, adjudged and decreed that the parental rights of the putative father ______ with respect to said child are hereby terminated in accordance with 23 Pa.C.S.A. Section 2503(d); said termination to extinguish the power or right of said ______ to object to or receive notice of adoption proceedings;
It is further ordered and decreed that custody of ______ is awarded to ______ .
_________________ , J.
Sec. 5. Alternative Procedure for Relinquishment. Petition to Confirm Consent to Adoption.
(a) A petition of an intermediary (or adoptive parents where there is no intermediary) to confirm the consents to an adoption where the parent has executed a consent to adoption as required by 23 Pa.C.S.A. Section 2711 and has failed for period of forty (40) days after executing the consent to file or proceed with a petition for voluntary relinquishment of parental rights, shall contain the following information:
(1) The name and address of the Petitioner and identity, i.e., parent, agency, intermediary;
(2) The name, address, age, racial background and religious affiliation of the parents, including the mother and father and all alleged parents and deceased parent;
(3) The marital status of the mother as of the time of birth of the child and during one (1) year prior thereto, and, if the mother has ever been married, the name of her husband or husbands, and her maiden name and how prior marriages were terminated;
(4) The name, age, date of birth, racial background, sex and religious affiliation of the child; the names of the child shall include all names by which the child has been identified on the birth certificate and any other legal document;
(5) The name and address of the agency, or the adopting parent(s) if non-agency adoption, having care of the child;
(6) The date when the child was placed with agency, or adopting parents if non-agency adoption;
(7) When the child is born out of wedlock, whether the mother and father of the child intend to marry;
(8) If the mother of the child was married during one (1) year prior to the birth of the child but has identified the father as a person other than her spouse, then the information as to the spouse (legal father) of the mother shall be set forth as required in subparagraph (2);
(9) If the father is unknown, whether there have been any claims of paternity or acknowledgment of paternity filed pursuant to 23 Pa.C.S.A. Section 5103;
(10) That the parent has executed a Consent to Adoption pursuant to 23 Pa.C.S.A. Section 2711 and has failed for a period forty (40) days after executing said consent to file or proceed with a petition for voluntary relinquishment of parental rights.
(11) If a putative father's rights are being terminated, pursuant to 23 Pa.C.S.A. 2504(c), that said putative father will not execute a consent to adoption as required by Section 2711 and has not filed an acknowledgement of paternity or claim of paternity pursuant to 23 Pa.C.S.A. Section 5103;
(12) That the agency, or the adopting parent(s) if a non-agency adoption, agree to accept custody of the child until such time as the child may be adopted;
(13) The reasons for seeking relinquishment.
The prayer shall request the Court to Confirm the consent to adoption and to terminate the parental rights of that parent to the child and to award custody to either the agency or, in the case of a non-agency adoption, to the adults intending to adopt. If the rights of the putative father are not to be terminated pursuant to 23 Pa.C.S.A. Section 2504(c), the prayer shall also request same.
(b) Exhibits. The petition shall have attached to it the following
(1) The joinder, if obtainable, of a parent who is not a petitioner;
(2) An original or certified copy of the birth certificate or certification of registration of birth of the child;
(3) The separate consent of the agency, or of the adult or adults intending to adopt, to accept custody of the child until such time as the child may be adopted;
(4) Original or certified copy of any previous divorce decrees relating to the mother and original or certified copy of any previous elections to resume maiden name relating to the mother;
(5) If the natural father is unknown or if the rights of the putative father are to be terminated pursuant to 23 Pa.C.S.A. Section 2504(c), the original or certified copy of documentation from the appropriate state agency certifying that no Acknowledgment of Paternity or Claim of Paternity has been filed.
(6) The original Consent signed by the parent pursuant to 23 Pa.C.S.A. Section 2711.
(c) Preliminary Decree and Hearing. Upon presentation of the petition the Court, by preliminary decree, shall fix a time for hearing which shall be not less than ten (10) days after filing of the petition. Notice shall be given to the parent(s) whose rights are to be terminated, the other parent (including any alleged father), the putative father whose rights could be terminated pursuant to 23 Pa.C.S.A. Section 2504(c), to the legal father if he has not been identified as the father, and to the parent(s) or guardian(s) of a natural parent who has not reached the age of 18 years.
Affidavit/Proof of the required notice of hearing on termination of parental rights shall be filed with Court at least five (5) days prior to the scheduled hearing.
The Petitioner unless otherwise permitted by the Court, and the witnesses to the Consent executed pursuant to Section 2711 of the Adoption Act, shall also appear unless:
(1) The signatures of the parent and witnesses are notarized; or
(2) One of the witnesses to the Consent is an attorney; or
(3) One of the witnesses to the Consent is a representative of a licensed adoption agency or child welfare agency representative.
(1) Notice to the Parent whose rights are being terminated.
(Caption of Case) TO: ______ (name of parent) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS YOU HAVE TO YOUR CHILD, (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING YOUR RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. A COPY OF THE NOTICE TO PETITIONER IS ATTACHED. YOUR ARE WARNED THAT EVEN IF YOU FAIL TO APPEAR AT THE SCHEDULED HEARING, THE HEARING WILL GO ON WITHOUT YOU AND YOUR RIGHTS TO YOUR CHILD MAY BE ENDED BY THE COURT WITHOUT YOUR 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh, PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(2) Notice to the Other Parent of Hearing on Petition to Confirm consent and Terminate Parental Rights.
(Caption of Case) TO: ______ (name of parent) _________________
MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (parent's name) HAS TO YOUR CHILD, ______ (name of Adoptee) ______ . THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ AT __.M. A COPY OF THE NOTICE TO ______ (parent's name) ______ IS ATTACHED HERETO.
_________________
Name of Attorney
Address
Telephone Number(3) Notice to Putative Father whose rights may be terminated pursuant to 23 Pa.C.S.A. Section 2504(c).
(Caption of Case) TO: ______ (putative father) _________________
FATHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (parent's name) ______ HAS TO YOUR CHILD, ______ (name of Adoptee) ______ THE COURT HAS SET A HEARING TO CONSIDER ENDING HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT __.M. A COPY OF THE NOTICE TO ______ (parent's name) ______ IS ATTACHED HERETO.
THIS PETITION ALSO ASKS THE COURT TO PUT AN END TO ALL RIGHTS YOU HAVE TO YOUR CHILD ______ (adoptee's name) ______ . YOU ARE WARNED THAT IF YOU FAIL TO FILE EITHER AN ACKNOWLEDGEMENT OF PATERNITY OR CLAIM OF PATERNITY PURSUANT TO 23 Pa.C.S.A. SECTION 5103 AND YOU FAIL TO APPEAR AT THIS HEARING FOR THE PURPOSE OF OBJECTING TO THE TERMINATION OF YOUR RIGHTS OR YOU FAIL TO FILE A WRITTEN OBJECTION TO THE TERMINATION OF YOUR RIGHTS WITH THE COURT PRIOR TO THIS HEARING, THE HEARING WILL GO ON 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh, Pennsylvania 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(4) Notice to Parent(s) or Guardian(s) of Parent who has not reached the age of 18 years.
(Caption of Case) TO: ______ MINOR NATURAL MOTHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (name of minor natural parent) ______ HAS TO (HIS/HER) CHILD ______ (adoptee's name). THE COURT HAS SET A HEARING TO CONSIDER ENDING (HIS/HER) RIGHTS TO (HIS/HER) CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT__.M. A COPY OF THE NOTICE TO ______ (parent's name) ______ IS ATTACHED HERETO.
_________________
Name of Attorney
Address
Telephone Number(d) Final Decree. A decree of termination in substantially the following form shall be submitted to the Court at the Hearing:
(1) DECREE
AND NOW, this ____ day of ______ , the foregoing Petition to Confirm Consent to Adoption having come on to be heard, upon consideration thereof and the consent attached thereto executed by ______ (name of parent) ______ , (mother/father) of (adoptee's name) ______ , and it appearing that ______ (name of parent) has failed for a period in excess of forty (40) days after executing the aforesaid consent to file or proceed with a Petition for Voluntary Relinquishment of Parental Rights, the Court finds that the facts averred in said petition are true and that the prayer of the petition should be granted;
NOW, THEREFORE IT IS ORDERED AND DECREED that the Consent to Adoption of ______ (adoptee's name) ______ executed by (parent's name) be and is hereby confirmed in accordance with the Adoption Act, 23 Pa.C.S.A. Section 2504 and the parental rights of (parent's name) ______ to ______ (adoptee's name) ______ be and are hereby terminated; said termination to extinguish the power or the right of said natural parent to object to or receive notice of adoption proceedings;
AND IT IS FURTHER ORDERED AND DECREED that custody of ______ (adoptee's name) ______ be and is hereby awarded to ______ agency name, or adopting parent(s) name(s) if non-agency adoption).
BY THE COURT:
_________________ J.
(2) If the rights of the putative father will also be terminated pursuant to 23 Pa.C.S.A. Section 2504(c), then a decree in substantially the following form shall be submitted to the Court at the hearing:
AND NOW, this ____ day of ______ , the foregoing Petition to Confirm Consent to Adoption having come on to be heard, upon consideration thereof and the consent attached thereto executed by ______ (parent's name) ______ (mother/father) ______ of ______(adoptee's name), and it appearing that ______ (parent's name) has failed for a period in excess of forty (40) days after executing the aforesaid consent to file or proceed with a Petition for Voluntary Relinquishment of Parental Rights, the Court finds that the facts averred in said petition are true and that the prayer of the petition should be granted:
NOW, THEREFORE IT IS ORDERED AND DECREED that the Consent to Adoption of ______ (adoptee's name) ______ executed by ______ (parent's name) ______ be and is hereby confirmed in accordance with the Adoption Act, 23 Pa.C.S.A. Section 2504 and the parental rights of ______ (parent's name) to ______ (adoptee's name) ______ be and are hereby terminated; said termination to extinguish the power or the right of said natural parent to object to or receive notice of adoption proceedings;
Furthermore, the Court finds that the putative father ______ (putative father's name) will not execute a consent to an adoption as required by 23 Pa.C.S.A. Section 2711, has not filed an Acknowledgment of Paternity or Claim of Paternity pursuant to 23 Pa.C.S.A. Section 5103, has not appeared to object to the termination of his parental rights to said child, and has not filed a written objection with this Court to the termination of his parental rights to said child;
NOW, THEREFORE, it is ORDERED AND DECREED that the parental rights of the putative father, (putative father's name) , with respect to said child are hereby terminated in accordance with 23 Pa.C.S.A. Section 2504(c); said termination to extinguish the power or right of said ______ (putative father's name) to object to or receive notice of Adoption proceedings;
IT IS FURTHER ORDERED AND DECREED that custody of ______ (adoptee's name) ______ is hereby awarded to ______ (agency, or adopting parent's name(s) if non-agency adoption.
BY THE COURT:
_________________ J.
Sec. 6. Involuntary Termination of Parental Rights Petition.
(a) A petition for involuntary termination of parental rights with respect to a child under the age of 18 years may be filed by any of the following:
(1) Any parent when termination is sought with respect to another parent;
(2) An agency; or
(3) The individual having custody of or standing in loco parentis to the child and who has filed a Report of Intention to Adopt.
(b) The petition shall contain the following information:
(1) The name and address of the petitioner and identity, i.e., parent, agency or other as permitted by the statute;
(2) The name, address, age, racial background and religious affiliation of the parent or parents and all alleged parents or person and any deceased parent;
(3) The marital status of the mother as of the time of the birth of the child and during one (1) year prior thereto, and if the mother has ever been married, the name of her husband or husbands and/or maiden name and how prior marriages were terminated;
(4) The name, age, date of birth, racial background, sex and religious affiliation of child; the name of the child shall include all names by which child has been identified on the birth certificate and any other legal document;
(5) The date when the Intention to Adopt was filed;
(6) The date when the child was placed with the adult or adults intending to adopt;
(7) When the child is born out of wedlock, whether the mother and father of the child intend to marry;
(8) If the child is born out of wedlock and the father has been identified, information as to the father shall be set forth as required in subparagraph (1);
(9) If the mother of the child was married within one (1) year prior to the birth of the child but identified the natural father as the person other than her spouse, then the information as to the spouse (legal father) of the mother shall be set forth as required in subparagraph (1);
(10) If the natural father is unknown, whether there has been any acknowledgement of paternity pursuant to 23 Pa.C.S.A. Section 5103;
(11) The grounds for involuntary termination;
(c) The prayer shall be for a decree terminating forever all parental rights with respect to the child and awarding custody of the child to the petitioning agency or individual.
(d) Exhibits. The petition shall have attached to it the following exhibits:
(1) An original or certified birth certificate or certification of registration of birth of the child;
(2) The separate consent of the adult or adults intending to adopt, to accept custody of the child, or agency intending to accept custody;
(3) The original or certified copy of any previous divorce decrees relating to the mother and original or certified copy of any elections to resume maiden name relating to the mother;
(4) The original or certified copy of Acknowledgement of Paternity or Claim of Paternity indicating that no acknowledgement of paternity or claim of paternity has been filed;
(5) A copy of the Court Order which adjudicated the child dependent, if child is currently under legal custody of Children and Youth Services or other child welfare services;
(6) If child was previously adopted, attach a certified copy of adoption decree.
(e) Preliminary Decree and Hearing.
Upon presentation of the petition the Court shall direct that it be filed and shall fix a date for hearing thereon not less than ten (10) days after the date of filing the petition. At least ten (10) days' notice of the hearing on the petition shall be given to the parent or parents, putative father, or parent of a minor parent whose rights are to be terminated and to the natural or appointed guardian of any parent or parents who is or are under the age of eighteen (18) years, by personal service or by registered mail to his or their last known address. Where personal service is not obtainable and the return receipt of the registered or certified mail does not bear the signature of the person to be notified, notice shall be given under appropriate Order of Court in accordance with Section 1(c) and (d) of Rule 12 of the Court, the last published notice to be at least ten (10) days prior to the date of hearing, the Court shall make a finding relative to the pertinent provisions of 23 P.A.C.S. Section 2531 of the Adoption Act, which finding shall be incorporated in a decree of termination of parental rights. The hearing may be private. Affidavit/Proof of Service of the required notices of hearing on termination of parental rights shall be filed with the Court at least five (5) days prior to the scheduled hearing.
(f) Notices.
(1) Notice to parent whose rights are being terminated of hearing on petition for involuntary termination of parental rights.
IN RE: ADOPTION OF _________________ , a minor.
No. ______ of ______ in the ORPHANS' COURT DIVISION OF THE ORPHANS' COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
TO: ______ (parent's name) _________________
MOTHER/FATHER OF ______(minor's name) ______ , A MINOR, BORN ______ (IN) ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS YOU HAVE TO YOUR CHILD ______ (insert name of child). THE COURT HAS SET A HEARING TO CONSIDER ENDING YOUR RIGHTS TO YOUR CHILD. A HEARING WILL BE HELD IN THE ORPHANS' COURT DIVISION, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH, PENNSYLVANIA ON ______ , AT , __.M. YOU ARE WARNED THAT EVEN IF YOU FAIL TO APPEAR AT THE SCHEDULED HEARING, THE HEARING WILL GO ON WITHOUT YOU AND YOUR RIGHTS TO YOUR CHILD MAY BE ENDED BY THE COURT WITHOUT YOUR 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
LAWYER REFERRAL SERVICE
The Allegheny County Bar Association 920 City-County Building
Pittsburgh, PA 15219
(412) 261-2088_________________
Name of Attorney
Address
Telephone Number(2) Notice to the other parent of hearing on petition to terminate parental rights.
(Caption of Case) TO: ______ (name of other parent) _________________ MOTHER/FATHER/LEGAL FATHER OF ______ (adoptee's name) ______ , BORN ON THE _____ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (parent's name), HAS TO YOUR CHILD ______ (name of adoptee). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHTS TO YOUR CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH PENNSYLVANIA ON ______ , __.M. A COPY OF THE NOTICE TO ______ (parent's name) IS ATTACHED HERETO.
_________________
Name of Attorney
Address
Telephone Number(3) Notice to parent(s) or guardian(s) of parent who has not reached the age of 18 years.
(Caption of Case) TO: ______ (name) _________________ MOTHER/FATHER OF ______ (adoptee's name) ______ , BORN ON THE ______ DAY OF ______ , ______ , AT ______ (hospital) ______ , ______ (city) ______ , ______ (county) ______ , ______ (state) ______ .
A PETITION HAS BEEN FILED ASKING THE COURT TO PUT AN END TO ALL RIGHTS ______ (name of minor natural parent), HAS TO (HIS/HER) CHILD ______ (adoptee's name). THE COURT HAS SET A HEARING TO CONSIDER ENDING HIS/HER RIGHT TO HIS/HER CHILD. THAT HEARING WILL BE HELD IN ORPHANS' COURT, 1700 FRICK BUILDING, 437 GRANT STREET, PITTSBURGH PENNSYLVANIA ON ______ , __.M. A COPY OF THE NOTICE TO ______ (parent's name) IS ATTACHED HERETO.
_________________
Name of Attorney
Address
Telephone Number(g) Final Decree. A decree of termination in substantially the following form shall be submitted to the Curt at the hearing:
DECREE AND NOW, this ____ day of ______ , the foregoing Petition for involuntary Termination of Parental Rights having come on to be heard, upon consideration thereof and of the supporting testimony and of the record, the Court finds that the facts averred in said Petition are true and the (name of parent) ______ (mother/father) (state grounds for termination with reference to minor) ___________________________
_______________________________________________
_______________________________________________ .
NOW THEREFORE, IT IS ORDERED, ADJUDGED AND DECREED, that all parental rights of ______(parent's name) ______ , to the minor ______ (minor's name), are hereby terminated, said termination to extinguish the power or the right of ______ (parent's name) , to object to or receive notice of adoption proceedings, and that the custody of the minor, ______ (minor's name), is hereby awarded to the ______ (agency, intermediary; or adoptive parent(s) ______ .
BY THE COURT:
_________________ J.
Sec. 7. Report of Intention to Adopt. Investigation.
(a) Every person now having or hereafter receiving or retaining custody or physical care of any child under the age of eighteen (18) years, other than that person's own child, grandchild, stepchild, brother or sister of the whole or half blood, or niece or nephew by blood, or adoption, for the purpose or with the intention of adopting the child, shall file a Report relating thereto in the office of the Clerk of the Orphans' Court Division of the Court of Common Pleas of Allegheny County and shall contain the information required by Sec. 2531 of the Adoption Act. The Report shall be verified by affidavit and be filed within thirty (30) days of the date when the child came into the custody or physical care of the person filing the Report.
Attach copy of preplacement report or homestudy (§ 2530-2531(7)). State whether birth mother has received counseling and where (§ 2505-2531(5)).
(b) When a Report of Intention to Adopt has been filed, the case will be referred to the Adoption Department for investigation, which shall report on matters alleged in the Report and any other matters that may affect the welfare of the child, including the matters set forth in Sec. 2535 of the Adoption Act.
(c) The Report of Intent to Adopt shall substantially conform with Form A set forth in the Appendix.
Sec. 8. Report of Intermediary.
(a) Intermediary—an intermediary is defined as any person or persons or agency acting between the parent or parents and the proposed adoptive parent or parents in arranging an adoption placement. If more than one person or agency acts in this capacity, they shall be identified as co-intermediaries.
(b) Each intermediary who or which has arranged the adoption placement of any child under the age of 18 years shall within six (6) months after filing the Report of Intention to Adopt, make and file with the Clerk of the Orphans' Court a written report under oath, and shall thereupon forthwith notify in writing the adopting parent or parents of the fact that the report has been filed and the date thereof.
(c) Contents of Report. The Report of Intermediary shall set forth the following information as required by 23 Pa.C.S.A. § 2533:
(1) The name and address of the intermediary.
(2) The name, sex, racial background, age, date and place of birth and religious affiliation of the child.
(3) The date of the placement of the child with the adopting parent or parents.
(4) The name, racial background, age, marital status as of the time of birth of the child and during one (1) year prior thereto, and religious affiliation of the parents of the child and the husband of the natural mother if he was her husband within one (1) year of the birth of the child.
(5) Identification of proceedings in which any decree of termination of parental rights, or parental rights and duties, with respect to the child was entered.
(6) The residence of the parents or parent of the child, if there has been no such decree of termination.
(7) A statement that all consents required by Section 2711 of the Adoption Act (relating to consents necessary to adoption) are attached as exhibits on the basis upon which the consents are not required.
(8) An itemized accounting of moneys and consideration paid or to be paid to 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.
(9) A full description and statement of the value of all property owned or possessed by the child.
(10) A statement that no provision of any statute regulating the interstate placement of children has been violated with respect to the placement of the child.
(11) If no birth certificate or certification of registration of birth can be obtained, a statement of the reason therefor.
(12) A statement that medical history information was obtained and if not obtained, a statement of the reason therefor.
(13) The report of the intermediary shall have attached to it the following exhibits:
1. An original or certified copy of the birth certificate or certification of registration of birth of the child if it can be obtained.
2. A certified copy of any decree of termination of parental rights or parental rights and duties made by a court order other than the court in which the petition for adoption will be filed.
3. A certified copy of the acknowledgement of paternity filed from the appropriate state agency that no claim or acknowledgement of paternity has been filed by the putative father, or a statement that the same has been previously filed with the Court.
4. Where applicable, a copy of the approved Interstate Compact Placement Request (ICPC-100-A).
(d) No intermediary shall place a child in the physical care or custody of a prospective adoptive parent or parents unless a home study containing a favorable recommendation for placement of a child with the prospective parent or parents has been completed within three (3) years prior thereto and which has been supplemented within one (1) year prior thereto. A home study shall be conducted by local public child care agency, an adoption agency or a licensed social worker designated by the Court to perform such study. See 23 Pa.C.S.A. § 2530.
(e) Where a home study required under 23 Pa.C.S.A. is in process but not yet completed, an intermediary may make an interim placement provided the requirements of 23 Pa.C.S.A. 2530(c) are met.
(f) The intermediary in making a placement may honor the preference of the natural parents as to the religious faith in which the adoptive parents intend to rear the adoptive child. However, no person shall be denied the benefits of a placement because of a religious belief in the use of spiritual means or prayer for healing, 23 Pa.C.S.A. § 2725.
(g) Report of the intermediary shall substantially conform with the form set forth in Form B in the Appendix to this Rule.
Sec. 9. Petition for Adoption
(a) The petition for adoption shall contain the following information:
(1) The full name, residence, marital status, age, occupation, religious affiliation and racial background of the adopting parent or parents and their relationship, if any, to the adoptee.
(2) A statement that a report of intention to adopt under 23 Pa.C.S.A. § 2531, a report of intermediary under 23 Pa.C.S.A. § 2530 and a homestudy and preplacement report under 23 Pa.C.S.A. § 2530 have been filed, if required.
(3) The name and address of the intermediary, if any.
(4) The full name of the adoptee and the fact and length of time of the residence of the adoptee with the adopting parent or parents.
(5) If there is no intermediary or if no report of the intermediary has been filed or if the adoptee is over the age of 18 years, all vital statistics and other information enumerated and required to be stated of record by 23 Pa.C.S.A. § 2533, so far as applicable.
(6) If a change in name of the adoptee is desired, the new name. When the person to be adopted has attained age eighteen (18) and a change of name is desired, Petitioner must submit evidence showing compliance with the law relating to change of name before a decree will be made.
(7) That all consents required by 23 Pa.C.S.A. § 2711 (relating to consents necessary to adoption) are attached as exhibits or the basis upon which such consents are not required, or a statement that same have been previously filed with the Court.
(8) That it is the desire of the petitioner or the petitioners that the relationship of parent and child be established between the petitioner or petitioners and the adoptee.
(9) If no birth certificate or certification of registration of birth can be obtained, a statement of the reason therefor and an allegation of the efforts made to obtain the certificate with a request that the Court establish a date and place of birth at the adoption hearing on the basis of the evidence presented.
(b) The petition for adoption shall contain the following exhibits:
(1) The consent or consents required and executed in accordance by Pa.C.S.A. § 2711 (relating to consents necessary to adoption). If the consents are executed before a notary public then one (1) witness to the consent shall be required to appear at the hearing; otherwise at least one (1) of the witnesses to said consent shall appear at the hearing. The consents need not be attached if they were previously filed with the Court, in which case, the Petition shall so state.
(2) Original or certified copy of birth certificate or certification of registration of birth of the child, unless previously filed with the record.
(3) Original or certified copy of marriage certificate of adoptors.
(4) Divorce decree of both of adopters, and election to resume maiden name, if applicable.
(5) Death certificate of former spouse of both adopters, if applicable.
(6) Death certificate of natural parents, if applicable.
(7) Original or certified copy of divorce decree, if any, of natural parents when petitioner is a step-parent.
(c) The petition shall substantially conform with Form C set forth in the appendix.
(d) A completed Certificate of Adoption Form H 105.091 shall be filed with the Court by Petitioners at the time the Petition for Adoption is filed.
(e) Hearing on Petition for Adoption—Disclosure of Fees and Costs.
The Court shall fix a time and a place for hearing. The hearing shall be private or in open Court as the Court deems appropriate.
At the hearing there shall be offered in evidence a report by petitioner, certified by counsel for the petitioner, setting forth the amount of fees and expenses paid or to be paid to counsel and any other fee, costs and expenses paid or to be paid to an intermediary or any other person or institution, in connection with the adoption.
(f) Requirements and Form of Decree
If satisfied that the statements made in the Petition for Adoption are true, that the welfare of the person proposed to be adopted will be promoted by the requested adoption, and that all requirements of the Adoption Act have been met, the Court shall enter a decree so finding and directing that the person proposed to adopted shall have all the rights of a child and heir of the adopting parent or parents, and shall be subject to the duties of a child to him, or them. In any case in which the petition is withdrawn or dismissed, the Court shall enter an appropriate order in regard to the custody of the child.
Sec. 10. Name of Adoptee
If requested by the petitioner, the decree may provide that the adoptee shall assume the surname of the adopting parent or parents and any given first and middle names that may be chosen. If the adoptee is over age 18 and desires a change in name evidence must be submitted showing compliance with the law relating to change of name before a decree will be made.
Sec. 11. Impounding of Proceedings.
All petitions, exhibits, reports, notes of testimony, decrees, and other papers pertaining to any proceeding under the Act shall be kept in the files of the Court as a permanent record thereof and withheld from inspection. Information in those records may only be made available under certain circumstances set forth in 23 Pa.C.S.A.
Section 2905. Requests for information shall be by petition or letter to the Administrative Judge of the Orphans' Court Division.
Sec. 12. Docket Entries.
Upon the filing of any decree under the Adoption Act, the Clerk shall enter on the docket an entry showing the date of the decree, the name of the adopting parent or parents and the post-adoption name of the adoptee. Information identifying the natural parents shall not be entered on the docket.
Sec. 13. Certificate of Adoption.
After the decree is entered the Clerk shall issue to the adopting parent or parents a certificate reciting that the Court has granted the adoption. The certificate shall not disclose the name of any natural parent or the original name of the person adopted. The certificate shall be accepted in any legal proceedings in the Commonwealth, as evidence of the fact that the adoption has been decreed.
It shall be the responsibility of counsel for the adopting parent to inform other Divisions of this Court of the entry of an adoption decree if this information is relevant to proceedings in other Divisions. It shall be the responsibility of counsel for the adopting parent to also complete and file the Division of Vital Records forms necessary to amend the adoptee's birth certificate.
Sec. 14. Other Requirements.
Medical history information shall be as set forth in Sec. 2902 of the Adoption Act, counseling shall be as set forth in Sec. 2505, and representation for child and parent shall be as set forth in Sec. 2313.
Sec. 15. Definitions.
1. Putative Father—The alleged or reputed father that is not the legal father of a child born out of lawful wedlock. A putative father shall include one who has filed a claim of paternity as provided in Pa. 23 C.S.A. § 5103 prior to the institution of proceedings.
2. Legal Father—The spouse of the mother during the one (1) year immediately preceding the birth of the proposed adoptee.
Appendix Form A
IN THE ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
In Re Adoption of ) ) ) No. ______ of ______ )
REPORT OF INTENTION TO ADOPT 1. PROPOSED ADOPTEE
Name of Child Sex _________________
Age, Date and Place of Birth _____________________________________
Racial Background _________________ Religious Affiliation _________________
The Birth Mother has (has not) had counseling relative to this adoption at _________________ .
2. PERSON(S) INTENDING TO ADOPT THE CHILD
Names and Ages of Adopting Parents ___________________________
Maiden Name of Adopting Mother _____________________________________
Address _____________________________________
Religious Affiliation _____________________________________
Date Child was Received _____________________________________
Other Adoptions _____________________________________
Adoptive Parent preplacement report or homestudy completed by _________________
On _______________________________________________
Attach a copy of the homestudy.
3. STATEMENT OF CIRCUMSTANCES SURROUNDING PROPOSED ADOPTING PARENT(S)
Include facts as to economic status, income, employment, home ownership, education, length of marriage, etc.
4. AGENCY OR INTERMEDIARY, AND AMOUNT OF FEE OR EXPENSES PAID OR TO BE PAID TO AGENCY OR INTERMEDIARY.
Name _____________________________________
Address _____________________________________
Amount of fees or expenses paid or to be paid to agency or intermediary:
$ _________________
We hereby certify that we now have custody of the child and intend to present a petition for adoption.
We acknowledge that we have been advised or know and understand that the natural parent(s) may revoke the consent to the adoption of this child until a Court has entered a decree terminating the parental rights and unless a decree terminating the parental rights has been entered, the natural parent may revoke the consent until the Court enters the final adoption.
_________________
Adoptive Father_________________
Adoptive MotherDate _________________
AFFIDAVIT
Commonwealth of Pennsylvania ) ) County of Allegheny ) SS: ) Before me, the undersigned authority, personally appeared ______ who being duly sworn according to law depose(s) and say(s) that the averments set forth in the foregoing Report of Intention to Adopt are true and correct.
_________________
Sworn to and subscribed before me
to this ____ day of ______ .
Appendix Form B
IN THE ORPHANS' COURT DIVISIONCOURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
In Re Adoption of ______ ) ) ) No. ______ of ______ )
REPORT OF INTERMEDIARY 1. The name of the Intermediary _____________________________________
Address _____________________________________
2. Proposed Adoptee:
Name _____________________________________
Sex ______ Age ______ Date of Birth ___________________________
Place of Birth _____________________________________
Racial Background _____________________________________
Religious Affiliation _____________________________________
3. Date of Placement of Proposed Adoptee with Adopting Parent(s)
_______________________________________________
4. Birth Mother
Name _____________________________________ Age ______
Racial Background _____________________________________
Religious Affiliation _________________ Marital Status: _________________
At date of birth _____________________________________
During one year prior to date of birth ___________________________
If no decree of termination of parental rights has been entered, indicate current address:
_______________________________________________
_______________________________________________
5. Birth Father
Name _____________________________________ Age ______
Racial Background _____________________________________
Religious Affiliation _________________ Marital Status: _________________
At date of birth _____________________________________
During one year prior to date of birth ___________________________
6. Legal Father (if applicable)
Name _____________________________________ Age ______
Racial Background _____________________________________
Religious Affiliation _________________ Marital Status: _________________
At date of birth _____________________________________
If no decree of termination of parental rights has been entered, indicate current address:
_______________________________________________
_______________________________________________
7. Identification of proceedings in which any decree of termination of parental rights, or parental rights and duties, with respect to the adoptee was entered. Attach a certified copy of the decree, unless said decree was entered in the Court of Common Pleas of Allegheny County, Pennsylvania.
8. All consents required by 23 Pa.C.S.A. Sec. 2711 (relating to consents necessary to Adoption) are attached as Exhibits hereto. If said consents have previously been filed with the Court, or if said consents are not necessary, explain why:
_______________________________________________
_______________________________________________
9. Set forth an itemized accounting of moneys and consideration paid or to be paid to or received by the Intermediary by reason of the adoption placement:
_______________________________________________
_______________________________________________
10. Set forth an itemized accounting of money and consideration paid or to be paid to or received by any other person(s) to the knowledge of the Intermediary by reason of the adoption placement.
11. Set forth a full description and statement of the value of all property owned or possessed by the adoptee.
12. Have the provisions of the statute regulating the interstate placement of children been complied with regarding the placement of the adoptee?
A copy of the signed approval from the Administrator of the Interstate Compact on the Placement of Children (when applicable) is attached hereto.
13. The original or certified copy of the adoptee's birth certificate or certification of registration of birth (is attached) (has been previously filed with the Court). If same cannot be obtained, state the reason therefor:
14. The medical history information on the birthparents has been obtained and provided to the adoptive parents, with identifying information having been deleted. If the medical history information has not been obtained, state the reason therefor:
_________________
Intermediary
AFFIDAVIT
Commonwealth of Pennsylvania ) ) ) SS: ) County of Allegheny ) Before me, the undersigned authority, personally appeared ______ who being duly sworn according to law, deposes and says that he/she is the intermediary in this case and has signed the within Report of Intermediary or that ______
(Agency) is the intermediary and that he/she is ______ of said agency and is authorized to sign the within Report of Intermediary on behalf of said agency and that the averments contained therein are true and correct.
_________________
Sworn to and subscribed before me
This ____ day of ______ .
Appendix Form C
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA, ORPHANS' COURT DIVISION
IN RE: ADOPTION OF ) ) No. ) PETITION FOR ADOPTION
TO THE HONORABLE, THE JUDGE OF SAID COURT:
The petition of ______ (adoptive father) ______ and ______ (adoptive mother) ______ respectfully represents:
1. That, he, she, they reside(s) at
_______________________________________________
_______________________________________________
_______________________________________________
That petitioners are living together. The petitioners' residence(s) for the past 5 years were:
_______________________________________________
_______________________________________________
2. That ______ (adoptive father) ______ , petitioner, is ______ years of age, having been born at ______ on ______ . He is of the ______ religion and of the ______ race. He is presently employed by ______ , having an annual income of ______ . His employers during the last 5 years were:
_______________________________________________
(names, address and dates)_______________________________________________
His blood or legal relationship to the adoptee is ___________________________
_______________________________________________
3. That ______ , petitioner, is ______ years of age, having been born at ______ on ______ . she is of the ______ religion and of the ______ race. She is presently employed by ______ , having an annual income of ______ .
Her employers during the last 5 years were:
_______________________________________________
_______________________________________________
(names, address and dates)_______________________________________________
Her blood or legal relationship to the adoptee, is ___________________________
_______________________________________________ .
4. That Petitioner(s) (is) (are) married, single, divorced.
Petitioners were married on ___________________________ at _________________
_______________________________________________ .
5. Identify all previous marriages of either Petitioner and method of termination.
1.) That ______ was divorced at No. ______ Term, ______ , ______ County, on ______ .
(date)2.) That ______ was divorced at No. ______ Term, ______ , ______ County, on ______ .
(date)Attach an original or certified copy of any divorce decrees.
6. That Petitioner(s) (is) (are) the parent(s) of the following children (indicate age, other parent, residence, by whom supported, and if adopted. If adopted, state date, term and court:
7. That the Report of Intention to Adopt and the Report of Intermediary have been filed if required.
_________________ _________________ _________________ (yes) (not required) (date filed) _________________ _________________ _________________ (yes) (not required) (date filed) 8. The name and address of the intermediary, if any, is __________
_______________________________________________
9. The name of the adoptee is ______ , of the ______ sex. The adoptee is _____ years of age, having been born at ______ on ______ . The adoptee has resided with Petitioner(s) for ______ , since ______ .
(mos./yrs.) (date)10. The petitioner(s) (is) (are) financially capable of supporting the adoptee, having an annual income of ______ .
THE FOLLOWING PARAGRAPHS, NOS. 11 AND 12, BOTH INCLUSIVE, MUST BE COMPLETED IF NO REPORT OF INTERMEDIARY HAS BEEN FILED OR IF THE ADOPTEE IS OVER THE AGE OF 18.
(Section 2701)
11. The petitioners have no knowledge of any money or thing of value, fees, expenses, or charges of any kind passing among or between them or any other person in connection with this adoption proceeding except:
(State fully if any exception.)
12. The adoptee's financial or property assets are as follows:
13. No provision of any statute regulating the interstate placement of children has been violated with respect to the placement of the adoptee. A copy of the signed approval from the Administrators of the Interstate Compact on the Placement of Children (if applicable) is attached.
14. a.) The name of the natural mother of the adoptee is ______ ; her residence is ______ ; her age is ______ ; her racial background is ______ ; her religious affiliation is ______ ; her marital status at the time of the birth of the adoptee was ______ . And her marital status during one (1) year prior thereto was ______ .
b.) The name of the natural father of the adoptee is ______ his residence is ______ ; ______ ; his age is ______ ; his racial background is ______ ; his religious affiliation is ______ ; his marital status at the time of the birth of the adoptee was ______ .
c.) The name of the legal father of the adoptee is ______ ; his residence is ______ ; ______ ; his age is ______ ; his racial background is ______ ; his religious affiliation is ______ ; his marital status at the time of the birth of the adoptee was ______ .
15. The following required exhibits are herewith submitted:
(a) An original or certified copy of the birth certificate or certification of birth of adoptee unless previously filed with Court, then state when.
(b) The consents required by Section 2711(a) of the Adoption Act unless if previously filed with Court, then state when.
16. There (has) (has not) been a decree of termination of parental rights or parental rights and duties. State date and docket number of termination. If termination is in a Court other than Court of Common Pleas of Allegheny County, attached certified copy of decree.
17. List the names, addresses and telephone numbers of four (4) references who have known petitioners for the last five years, include a clergy, family doctor and two (2) non-relatives.
1. _______________________________________________
(clergy)2. _______________________________________________
(family physician)3. _______________________________________________
(non relative)4. _______________________________________________
(non-relative)18. That it is the desire of the petitioner(s) that the relationship of parent and child be established between petitioner(s) and the adoptee.
19. That it is desired that the new name of adoptee be
_______________________________________________
20. That the parent(s) of the adoptee, (is) (are) not entitled to the benefits of the Soldiers' and Sailors' Act of 1949, as amended (50 U.S.C.A. 501).
21. Attached hereto are consents to adoption given by the adoptee, if over twelve years of age, and the adopting parent's spouse, unless he or she joins in the adoption petition.
22. Your petitioner(s) declare(s) that (he) (she) (they) will perform all the duties of parent(s) to such adoptee, and believe(s) that the welfare of the adoptee will be promoted by this adoption and therefore, pray your Honorable Court enter a decree that ______ shall be the legally adopted child and heir of petitioner(s) and that the name of said adoptee shall hereafter be ______ .
Date _________________ _________________
_________________
(Signatures of Petitioners)
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF ALLEGHENY ) ss ) ) Before me, the undersigned authority, personally appeared __________
_______________________________________________
(Names of Petitioners)who, being duly sworn, according to law, depose(s) and say(s) that he, she, they are the petitioner(s) in the above entitled proceedings and that the averments set forth in the foregoing petition are true and correct.
Sworn to and subscribed before
me this ____ day of ______ .
_________________
(Notary Public)My Commission Expires:
CONSENT OF ADOPTEE OVER 12
COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF ALLEGHENY ) I, _________________, being duly sworn according to law, hereby depose and say:
(Name of Adoptee)That I am the person whose adoption is proposed in these proceedings; that I am over twelve (12) years of age, having been born on ______ , that I am familiar with the facts stated in the petition for adoption filed in these proceedings; and that the facts contained therein are true to the best of my knowledge and belief.
I hereby consent to the proposed adoption.
_________________
(Name of Adoptee)Sworn to and subscribed before me this ____ day of ______ .
_________________
(Notary Public)My Commission Expires:
I, ______ , of ______ , have witnessed the execution by ______ ,
(full name) (address) (birth parent)
of the above to Adoption of ______ , on the ____ day of ______ , ______ . My
(adoptee)
relationship to ______ is ______ ._________________
(signature of witness)
[Pa.B. Doc. No. 16-1290. Filed for public inspection July 29, 2016, 9:00 a.m.] _______
10 Sections marked by asterisk (*) must be completed by counsel before Court presentation.
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