[51 Pa.B. 4267]
[Saturday, August 7, 2021]
[Continued from previous Web Page]
INDEX TO APPENDIX
ORPHANS' COURT AND REGISTER OF WILLS FORMS ADOPTED BY SUPREME COURT PURSUANT TO Pa. O.C. Rule 1.8 Available as Fill-in Forms on Website
of Administrative Office of Pennsylvania Courts
http://www.pacourts.us/forms/for-the-public/orphans-court-forms
Orphans' Court and Administration Forms * * * * * F. Adoption Forms
1. Notice of Orphans' Court Proceedings to be Filed With Clerk in Dependency Proceeding by Solicitor of County Agency (Pa. O.C. Rule 15.5)
a. Praecipe to Clerk in Dependency Proceeding of Filing of a Petition to Terminate Parental Rights, Confirm Consent, or Adopt A-01 b. Praecipe to Clerk in Dependency Proceeding of Entry of Decision Disposing of Petition A-02 c. Praecipe to Clerk in Dependency Proceeding of Filing of Notice of Appeal A-03 d. Praecipe to Clerk in Dependency Proceeding of Entry of Decision Disposing of Appeal A-04 2. Notice to Provide Medical Information and Determine Access to Identifying Information A-05 3. Foreign Adoption Forms a. Forms for Registration of Foreign Adoption Decree (Pa. O.C. Rule 15.14) i) Instructions for Filing Petition A-06 ii) Petition to Register Foreign Adoption Decree A-07 iii) Proposed Final Decree A-08 b. Forms for Adoption of a Foreign Born Child (Pa. O.C. 15.15) i) Petition for Adoption of a Foreign Born Child A-09 ii) Report of the Intermediary A-10 iii) Preliminary Decree A-11 iv) Final Decree A-12
IN THE COURT OF COMMON PLEAS
______ COUNTY PENNSYLVANIA
JUVENILE COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County) In the Interest
:
of _________________ , a Minor
:
[Initials of Minor]
:
:
Date of Birth _________________
:Docket No.: CP-_____ DP-_____ -20__
TO CLERK OF _____________________________________ :
[Title of Clerk Maintaining Dependency Docket]1Please kindly record the following in the CPCMS—Dependency Module:
I hereby notify you that the following has been filed on ______ [DATE OF FILING] ______ with the Orphans' Court in ______ [NAME] ______ County concerning the above-child:
[ ] A petition to relinquish parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] _____ .
[ ] A petition to terminate parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] _____ .
[ ] A petition to confirm consent of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] ______ .
[ ] A petition for adoption.
Date: _________________
_________________
On behalf of: [County Agency]
IN THE COURT OF COMMON PLEAS
______ COUNTY PENNSYLVANIA
JUVENILE COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County) In the Interest
:
of _________________ , a Minor
:
[Initials of Minor]
:
:
Date of Birth _________________
:Docket No.: CP-_____ DP-_____ -20__
TO CLERK OF _____________________________________ :
[Title of Clerk Maintaining Dependency Docket]1Please kindly record the following in the CPCMS—Dependency Module:
I hereby notify you that the following has entered on ______ [DATE OF FILING] ______ by the Orphans' Court in ______ [NAME] ______ County concerning the above-child:
[ ] An order granting denying (circle one) the petition to relinquish parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] _________________ .
[ ] An order granting denying (circle one) the petition to terminate parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] _________________ .
[ ] An order granting denying (circle one) the petition to confirm consent of ____ [INITIALS OF PARENT(S) NAMED IN THE PETITION] _________________ .
[ ] With the above-order relinquishing or terminating parental rights or confirming the consent of the parent(s), the child is available for adoption.
Do not check if at least one parent still has parental rights.
[ ] An order granting denying (circle one) the petition for adoption.
Date: _________________
_________________
On behalf of: [County Agency]
IN THE COURT OF COMMON PLEAS
______ COUNTY PENNSYLVANIA
JUVENILE COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County) In the Interest
:
of _________________ , a Minor
:
[Initials of Minor]
:
:
Date of Birth _________________
:Docket No.: CP-_____ DP-_____ -20__
TO CLERK OF _____________________________________ :
[Title of Clerk Maintaining Dependency Docket]1Please kindly record the following in the CPCMS—Dependency Module:
I hereby notify you that an appeal has been filed on ______ [DATE] ______ concerning the above-child from the following Orphans' Court order:
[ ] An order granting denying (circle one) the petition to relinquish parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE ORDER] _________________ .
[ ] An order granting denying (circle one) the petition to terminate parental rights of ____ [INITIALS OF PARENT(S) NAMED IN THE ORDER] _________________ .
[ ] An order granting denying (circle one) the petition to confirm consent of ____ [INITIALS OF PARENT(S) NAMED IN THE ORDER] _________________ .
[ ] An order granting denying (circle one) the petition for adoption.
Date: _________________
_________________
On behalf of: [County Agency]
IN THE COURT OF COMMON PLEAS
______ COUNTY PENNSYLVANIA
JUVENILE COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County) In the Interest
:
of _________________ , a Minor
:
[Initials of Minor]
:
:
Date of Birth _________________
:Docket No.: CP-_____ DP-_____ -20__
TO CLERK OF _____________________________________ :
[Title of Clerk Maintaining Dependency Docket]1Please kindly record the following in the CPCMS—Dependency Module:
I hereby notify you that the appeal from the Orphans' Court order concerning the above-child has been disposted ______ [DATE] ______ in the following manner:
[ ] Quashed
[ ] Affirmed
[ ] Reversed
[ ] Vacated & Remanded[ ] Other: __________
Date: _________________
_________________
On behalf of: [County Agency]COURT OF COMMON PLEAS OF _________________ COUNTY
ORPHANS' COURT
DIVISION
IMPORTANT NOTICE
NOTICE OF PARENTAL RIGHTS TO PROVIDE MEDICAL INFORMATION AND
DETERMINE ACCESS TO IDENTIFYING INFORMATIONTo ___________________________ :
Your parental rights to ___________________________ have been terminated. Nevertheless, you have the ability (i) to make medical and personal information about you known to the adopting parents and/or your child; and (ii) to control if and how your identifying information is disclosed to the adopting parents and/or your child.
Forms to provide medical, personal, or social history information, update such information, authorize or restrict the release of identifying information, or withdraw authorization to release identifying information can be found online at www.adoptpakids.org/Forms.aspx or by calling 800-227-0225. These forms are provided free by PAIR (Pennsylvania Adoption Information Registry, Department of Human Services); they should be completed and returned to PAIR.
You may also file this information with the court using the same forms provided by PAIR or providing a written statement in your own words signed by you. Please make sure to include the case caption and docket number on your form or statement and send the documents to:
___________________________
___________________________
___________________________
___________________________You may update this information as necessary to reflect a change in address or any other information pertaining to either biological parent.
Your consent to release identifying information may be withdrawn at any time by filing a withdrawal of consent form with PAIR and the court; likewise, you can change a prior refusal to provide identifying information by sending and filing an authorization to release.
Finally, for information about having your name redacted from your child's birth certificate, please visit https://www.health.pa.gov/topics/certificates/Pages/Adoptions.aspx . For assistance, call 724-656-3100 or toll-free 1-844-228-3516.
For any additional questions, you can contact PAIR, your Children & Youth Social Service Agency, any private licensed adoption agency, or the Orphans' Court Division of your county's Common Pleas Court.
By: ___________________________
Clerk, Orphans' Court
INSTRUCTIONS FOR FILING
PETITION TO REGISTER FOREIGN ADOPTION DECREE
PURSUANT TO 23 Pa.C.S. § 2908When a child is adopted in conformity with the laws of a foreign country, the adopting parent(s) may register the Foreign Adoption Decree so that the Decree is considered full and final, enforceable as if entered pursuant to the Pennsylvania Adoption Act, and a Pennsylvania birth certificate can be obtained.
Adopting parent(s) seeking to register the Foreign Adoption Decree must:
1. Complete, sign, and date the Petition to Register Foreign Adoption Decree and Verification. If a Foreign Adoption Decree shows that there are two adopting parents, both parent(s) must execute the Petition to Register Foreign Adoption Decree.
2. Attach the following documents to the Petition:
• A copy of the Foreign Adoption Decree;
• A copy of the child's birth certificate. If no birth certificate was issued, a copy of any other birth identification issued by the country of birth should be attached. If no birth certificate or birth identification can be obtained, an Affidavit stating the reason should be submitted;
• A copy of the child's United States Visa;
• An English translation of all documents not in English, certified by a translator to be true and correct;
• Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed;
• Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency;
• If available, a copy of U.S. Government Form N-560 and/or a copy of the child's U.S. Passport.
3. The Petition to Register with the attachments should be filed with the Clerk of the Orphans' Court Division of the Court of Common Pleas in the county in which the adopting parent(s) reside(s), except for Philadelphia County resident(s), who must file with the Family Court Division. A filing fee will be charged in accordance with the fee schedule of the county court.
After the Petition to Register is filed, it will be submitted to the court for review. If the Petition to Register and accompanying documents establish that the foreign adoption of the child is full and final, the court will enter a Decree directing the registration of the Foreign Adoption Decree. The Clerk of the appropriate court will then issue a certificate of adoption and transmit to the Department of Health, Division of Vital Records Forms HD01273F and HD01275F, and if provided by the adopting parent(s), a copy of U.S. Government Form N-560 and/or a copy of the child's United States passport.
If the court cannot determine that the foreign adoption is full and final, it will enter a Decree denying the petition. In that case, it will be necessary to proceed under Pa. O.C. Rule 15.15.
Some of the following are reasons why a foreign adoption may not be a full and final adoption eligible for registration:
• both adopting parents were not present for the adoption hearing in the foreign country and the foreign country is not a Hague Convention country; or
• the sole adopting parent was not present at the adoption hearing in the foreign country and the foreign country is not a Hague Convention country; or
• the foreign court did not enter a final adoption Decree or Order or its equivalent; or
• the child's United States Visa is not the type that affords the child full United States citizenship.
If the child has an IH-4 or IR-4 United States Visa, it will be necessary to proceed under Pa. O.C. Rule 15.15.
IN THE COURT OF COMMON PLEAS
_________________COUNTY, PENNSYLVANIA
ORPHANS' COURT (FAMILY COURT DIVISION IN PHILADELPHIA)
IN RE: FOREIGN ADOPTION OF ___________________________
FILE NO. ___________________________
PETITION TO REGISTER FOREIGN ADOPTION DECREE PURSUANT TO 23 Pa.C.S. § 2908 1. Petitioner(s), the Adopting Parent(s) of the above-named adopted child, is/are _________________ .
2. Petitioner(s) reside(s) in _________________ County, Pennsylvania, at
__________
(Street Address)
__________
(City, State, Zip)3. Has any other court in this Commonwealth or in any other state reviewed, registered, finalized or otherwise assumed jurisdiction over the foreign adoption decree being registered here:
(check one) [ ] Yes [ ] No
If yes, please provide the name of the court, the state, and county, what was previously presented to the court and the resulting decision from the court (attach all court decrees):
__________________________________________________4. The full name of the adopted child at birth as listed on the foreign birth certificate, if available, was ______
___________________________ .
5. The full name of the adopted child as written on the foreign adoption decree is _________________ .
6. The full name of the adopted child as he or she is to be known from this time forward is ______ .
7. The date of birth of the adopted child is ___________________________ .
8. The date of the foreign adoption decree is ___________________________ .
9. The type of United States Visa issued to the adopted child is:
(check one) [ ] IR-2
[ ] IR-3
[ ] IH-3
[ ] IR-4
[ ] IH-4
10. The following documents are attached to this Petition:
a. Copy of child's birth certificate or other birth identification issued by country of birth; if none, an affidavit of adopting parent(s) stating why none is available.
b. Copy of Decree of Adoption issued by foreign government; if Decree is not in English, an English translation certified by the translator to be true and correct.
c. Copy of adopted child's United States Visa.
d. Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed.
e. Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency.
f. Copy of U.S. Government Form N-560, Certificate of Citizenship, and/or a copy of the child's United States passport, if either or both documents are available.
WHEREFORE, Petitioner(s) request(s) that this Court enter a Decree authorizing the registration and docketing of the attached Foreign Adoption Decree with the Clerk of the appropriate Court and decreeing that
_____________________________________ shall henceforth be known as (Name of child as written on Foreign Adoption Decree)
_________________ and shall have all the rights of a child and heir of the Petitioner(s).
(Child's name from this time forward)__________
Signature of Adopting Parent1
__________
Signature of Adopting Parent___________________________
Daytime telephone no. for Adopting Parent(s)
VERIFICATION TO PETITION TO REGISTER FOREIGN ADOPTION DECREE
PURSUANT TO 23 Pa.C.S. § 2908I/We, _________________ , verify that I/we am/are the Petitioner(s) named in the foregoing Petition, that I/we have read and understand the information set forth in the Instructions to the Petition to Register Foreign Adoption Decree, and that the facts set forth in the foregoing Petition are true and correct to the best of my/our knowledge, information and belief. I/We further verify that all documents attached to this Petition are true and correct copies of the originals. I/We understand that false statements made herein are subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
Date: _________________
__________Signature of Adopting Parent
__________Signature of Adopting Parent
IN THE COURT OF COMMON PLEAS
_________________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: FOREIGN ADOPTION OF _________________
ADOPTION NO. ______
FINAL DECREE AND NOW, this ______ day of ______ , 20____ , it is hereby ORDERED and DECREED that the Petition of __________ (Adopting Parent(s))
___________________________ to Register Foreign Adoption Decree is GRANTED and that this Court authorizes the registration and docketing of the Foreign Adoption Decree entered on _________________ by _________________ in _________________ .
(Date of Foreign Adoption Decree) (Name of Foreign Court) (Foreign Country)It is FURTHER ORDERED and DECREED that the above Foreign Adoption Decree shall be enforceable as if this Court had entered the Decree and that henceforth this child __________ (Name of child as written on Foreign Adoption Decree)
shall be known as _____________________________________ and shall (Child's name from this time forward)
have all the rights of a child and heir of ___________________________ .
(Adopting Parent(s))BY THE COURT:
__________
IN THE COURT OF COMMON PLEAS
_________________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: FOREIGN ADOPTION OF _________________
ADOPTION NO. ______
FINAL DECREE AND NOW, this ______ day of ______ , 20____ , it is hereby ORDERED and DECREED that the Petition of __________ (Adopting Parent(s))
___________________________ to Register Foreign Adoption Decree is DENIED.
BY THE COURT:
__________
IN THE COURT OF COMMON PLEAS OF
_________________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: ADOPTION OF _________________
(initials only)
ADOPTION NO. ______
PETITION FOR ADOPTION OF A FOREIGN BORN CHILD To the Honorable, the Judge of said Court:
The Petition of _____________________________________ under (Name(s) of Adopting Parent(s))
23 Pa.C.S. §§ 2701 and 2908 respectfully states that:1. At least one of the Petitioners filing this Petition is a resident of the Commonwealth of Pennsylvania and has resided in this Commonwealth since ___________________________ .
(Provide at least month and year)2. No other court in this Commonwealth or in any other state has reviewed, registered, finalized or otherwise assumed jurisdiction over the adoption of this child, except as follows:
______________________________
(Provide name of court, county and state)Explain the proceeding previously initiated and the resulting decision from the court (attach all court decrees):
__________________________________________________3. Petitioner(s) desire(s) to adopt this child known as ___________________________ , (Name of child as written on Foreign Decree)
and intend(s) that such child shall be treated as one of (his/her/their) heirs and hereby declare(s) that (he/she/they) will perform all the duties of parent(s) to him/her.4. The child has entered the United States pursuant to a United States Visa. A true and correct copy of the United States Visa is attached as an exhibit to this Petition. The United States Visa was issued as an:
(Please check one) [ ] IR-2
[ ] IR-3
[ ] IH-3
[ ] IR-4
[ ] IH-4
5. a) The child's full name as shown on the United States Visa is
_______________________________________________ .
b) The full birth name of the child as listed on the foreign birth certificate (if available) is
_______________________________________________ .
c) The full name of the child as it appears on the foreign decree is
_______________________________________________ .
d) The full name of the child as he/she is to be known from this time forward is
_______________________________________________ .6. The child has resided with Petitioner(s) for the following length of time __________
_______________________________________________ .7. Information concerning the Petitioner(s), the adopting parent(s), is as follows:
a) Adopting Parent #1:
1) Full name __________2) Residence ____________________3) Marital status __________4) Age __________5) Occupation __________
6) Religious affiliation __________
7) Racial background __________
8) Relationship to adoptee by blood or marriage, if any __________
9) Daytime telephone no. __________b) Adopting Parent #2:
1) Full name __________2) Residence ____________________3) Marital status __________4) Age __________5) Occupation __________
6) Religious affiliation __________
7) Racial background __________
8) Relationship to adoptee by blood or marriage, if any __________
9) Daytime telephone no. __________8. The following reports, as applicable, have been completed as of the dates set forth below. A true and correct copy of each of these reports is attached as an exhibit to this Petition.
a) Report of Intermediary described in 23 Pa.C.S. § 2533
Completion Date: _________________
b) Home Study and/or Preplacement Reports described in 23 Pa.C.S. § 2530
Completion Date: _________________
c) Investigation Reports described in 23 Pa.C.S. § 2535
Completion Date: _________________
d) Postplacement Reports, if any
Completion Date (if applicable): _________________9. Information concerning the intermediary agency, if any, is as follows:
Name of agency __________
Address __________
____________________
Telephone no. __________
County where office is located __________10. If there is no Report of an Intermediary, the following information is being provided by the Petitioner(s) as to the adoptee or adopted child:
a) Sex __________
b) Racial background __________
c) Age __________
d) Birth date __________
e) Birthplace __________
f) Places of residence since birth __________
__________
__________
g) Religious affiliation __________
h) A full statement of the value of all property owed or possessed by the child, if any __________
__________
__________
__________
__________i) State whether medical history information was obtained, and if not, explain why not __________
__________
____________________11. If there is no Report of an Intermediary, and the adoptee or adopted child is under 18 years of age, provide the following information as to the birth mother, if known:
a) Name __________
b) Residence or last known address __________
c) Racial background __________
d) Age __________
e) Marital status as of the time of the birth of child __________
f) Marital status during one year prior to birth of child __________
g) Religious affiliation __________
h) Birth mother's parental rights were terminated by decree of
__________
_____________________________________ dated ______12. If there is no Report of an Intermediary, and the adoptee or adopted child is under 18 years of age, provide the following information as to the birth father, if known:
a) Name __________
b) Residence or last known address __________
__________
c) Racial background __________
d) Age __________
e) Marital status as of the time of the birth of child __________
f) Marital status during one year prior to birth of child __________
g) Religious affiliation __________
h) Birth father's parental rights were terminated by decree of
__________
__________
_____________________________________ dated ______13. If there is no Report of an Intermediary, attach a copy of the birth certificate, with an English translation for those birth certificates not in English, certified by a translator to be true and correct. If no birth certificate or other birth identification issued by the country of birth can be obtained, a statement of the reason and a detailed explanation of the efforts made to obtain the certificate are required and attached as an exhibit to this Petition.
14. If there is no Report of an Intermediary, attach copies of any foreign decrees and/or documents concerning this adoption, including any decree terminating the parental rights of birth mother and/or birth father, if needed, with an English translation for those decrees and/or documents not in English, certified by a translator to be true and correct translations of the foreign decrees and/or documents.
15. If there is no Report of an Intermediary, attach all consents required by Section 2711 of the Adoption Code, 23 Pa.C.S. § 2711. If consents are not required, explain:
____________________________________________________________16. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed.
17. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency.
18. Attach U.S. Government Form N-560, Certificate of Citizenship, and/or a copy of the child's United States passport, if either or both documents are available.
19. It is the desire of the Petitioner(s) to have a parent-child relationship established between the Petitioner(s) and the adoptee or adopted child.
WHEREFORE, Petitioner(s) pray your Honorable Court to enter a Final Decree that the child proposed to be adopted shall have all the rights of a child and heir of Petitioner(s) and Petitioner(s) shall be subject to the duties as parents of such child, and that the child's name shall henceforth be
_______________________________________________ .DATE: _________________
_________________Signature of Adopting Parent2
__________
Signature of Adopting Parent
________________________________________(If represented, counsel's name, address, and telephone number)
VERIFICATION TO PETITION FOR ADOPTION OF A FOREIGN BORN CHILD I/We, _________________ , verify that I/we are the Petitioner(s) named in the foregoing Petition and that the facts set forth therein are true and correct to the best of my/our knowledge, information and belief. I/We further verify that all documents attached to this Petition are true and correct copies of the originals. I/We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
DATE: _________________
_________________Signature of Adopting Parent
__________
Signature of Adopting Parent
IN THE COURT OF COMMON PLEAS OF
_________________ , PENNSYLVANIA
ORPHANS' COURT
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: ADOPTION OF _________________
(initials only)
ADOPTION NO. ______ REPORT OF THE INTERMEDIARY IN THE ADOPTION OF A FOREIGN BORN CHILD
The report of the agency, _________________ , as intermediary, under 23 Pa.C.S. § 2533, states as follows:
1. Intermediary's address: __________
__________
Intermediary's telephone no: __________
County where office is located: __________2. The facts as to the adoptee or adopted child are:
a) Name __________
b) Sex __________
c) Racial Background __________
d) Age __________
e) Birth Date __________f) Birthplace __________
g) Religious affiliation __________3. Date of the placement of the child with the Petitioner(s), adopting parent(s),
__________4. If known, the facts as to the birth mother are:
a) Name __________
b) Residence or last known address __________
__________
c) Racial background __________
d) Age __________
e) Marital status as of the time of the birth of the child __________
f) Marital status during one year prior to birth of the child __________
g) Religious affiliation __________
h) Birth mother's parental rights were terminated by decree of
______________________________dated __________
5. If known, the facts as to the birth father are:
a) Name __________
b) Residence or last known address __________
c) Racial background __________
d) Age __________
e) Marital status as of the time of the birth of the child __________
f) Marital status during one year prior to birth of the child __________
g) Religious affiliation __________
h) Birth father's parental rights were terminated by decree of
______________________________dated __________
6. All consents required by 23 Pa.C.S. § 2711 are attached to this Report as exhibits or are not required for the following reasons, provide explanation:
____________________________________________________________________________________________________________________________________________________________________________________7. a) Attach a true and correct copy of the birth certificate or a registration of the birth by the country of birth, with an English translation for those birth certificates or registrations of birth not in English certified by a translator to be true and correct. If no birth certificate or other birth identification issued by the country of birth can be obtained, a statement of the reason and a detailed explanation of the efforts made to obtain the certificate are attached as exhibits to this Report.
b) Attach copies of any foreign decrees and/or documents concerning this adoption, including any decree terminating the parental rights of birth mother and/or birth father, with an English translation for those decrees and/or documents not in English, certified by a translator to be true and correct translations of the decrees and/or documents.8. Attach a verified list of itemized fees and/or expenses paid or to be paid to or received by the intermediary and/or 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, if any, is as follows:
____________________________________________________________________________________________________________________________________________________________________________________10. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of the child.
11. The child's medical history information was obtained and is available, except as follows:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DATE: _________________
_________________
Signature
__________
Print Name of signor
__________
Title
__________
Name of agency
VERIFICATION TO REPORT OF INTERMEDIARY I, _____________________________________ , verify that I am __________
(Title)
__________(Name of Agency)
and I am authorized to take this verification on its behalf, and that the facts set forth in the foregoing Report are true and correct to the best of my knowledge, information and belief. I further verify that all documents attached to this Report are true and correct copies of the originals. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.DATE: _________________
__________
Signature
IN THE COURT OF COMMON PLEAS OF
_________________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: ADOPTION OF _________________
(initials only)
ADOPTION NO. ______
PRELIMINARY DECREE AND NOW, this _________________ day of ______ , 20____ , upon consideration of the within Petition and on the motion of _________________ , Esquire, attorney for Petitioner(s) or ___________________________ , Pro Se, a hearing thereon is fixed for _________________ in _________________ before the Honorable _________________ at ____ am/pm.
Notice shall be given to the following persons and or entities having any legal and/or physical rights to the child:
1. NAME _________________
ADDRESS _________________
_________________
RELATIONSHIP ______2. NAME _________________
ADDRESS _________________
_________________
RELATIONSHIP ______3. NAME _________________
ADDRESS _________________
_________________
RELATIONSHIP ________________
J.
IN THE COURT OF COMMON PLEAS OF
_________________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)
IN RE: ADOPTION OF _________________
(initials only)
ADOPTION NO. ______
FINAL DECREE AND NOW, this _________________ day of _________________ , 20____ , upon consideration of the within Petition and after the hearing thereon, the Court having made an investigation to verify the statements of the Petition and other facts to give the Court full knowledge as to the desirability of the proposed adoption; and the Court, being satisfied, finds that the statements made in the Petition are true, that the needs and welfare of the child proposed to be adopted will be promoted by this adoption, and that all requirements of the Adoption Act have been met, it is hereby
ORDERED, ADJUDGED and DECREED that this child, ___________________________ is (Name of child as written on Foreign Decree)
hereby adopted, shall be known as ___________________________ and shall (Child's name from this time forward)
have all the rights of a child and heir of ___________________________ ,
(Adopting Parent(s))
and shall be subject to the duties of a child to said adopting parent(s).__________
J.
[Continued on next Web Page] _______
1In the First Judicial District (i.e., Philadelphia County), this Clerk will be the Clerk of the Family Court division; in the Fifth Judicial District (i.e., Allegheny County), this Clerk will be personnel at the Department of Records for the Civil/Family division; and in most of the other counties, the Clerk will be the Clerk of the Juvenile Court division.
1In the First Judicial District (i.e., Philadelphia County), this Clerk will be the Clerk of the Family Court division; in the Fifth Judicial District (i.e., Allegheny County), this Clerk will be personnel at the Department of Records for the Civil/Family division; and in most of the other counties, the Clerk will be the Clerk of the Juvenile Court division.
1In the First Judicial District (i.e., Philadelphia County), this Clerk will be the Clerk of the Family Court division; in the Fifth Judicial District (i.e., Allegheny County), this Clerk will be personnel at the Department of Records for the Civil/Family division; and in most of the other counties, the Clerk will be the Clerk of the Juvenile Court division.
1In the First Judicial District (i.e., Philadelphia County), this Clerk will be the Clerk of the Family Court division; in the Fifth Judicial District (i.e., Allegheny County), this Clerk will be personnel at the Department of Records for the Civil/Family division; and in most of the other counties, the Clerk will be the Clerk of the Juvenile Court division.
1 When there are two adopting parents, both must sign.
1 When there are two adopting parents, both must sign.
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
