THE COURTS

Title 255—LOCAL COURT RULES

WESTMORELAND COUNTY

Order Adopting New Form for Report of Intermediary; No. 3 of 2023

[53 Pa.B. 1665]
[Saturday, March 25, 2023]

Administrative Order of Court

 And Now, this 14th day of March, 2023, It Is Hereby Ordered that the prior version of the Westmoreland County Orphans' Court Procedural Form ''Report of Intermediary'' is hereby rescinded and the new form ''Report of Intermediary'' appended to this Order as Exhibit ''A,'' is hereby adopted.

 This change is effective 30 days after publication in the Pennsylvania Bulletin.

By the Court

CHRISTOPHER A. FELICIANI, 
President Judge

IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF
WESTMORELAND COUNTY, PENNSYLVANIA

IN RE:	:
ADOPTION OF	:
	:	No:   OF
	:
	:
(Adoptee's name as on birth certificate)	:	ATTORNEY:

REPORT OF INTERMEDIARY
(23 Pa.C.S. § 2533)

 The INTERMEDIARY is required to file a report within six months after filing the Report of Intent to Adopt and shall forthwith notify adopting parents of the report and filing thereof, in writing. [An INTERMEDIARY is any person or persons or agency acting between the parent or parents and the proposed adoptive parent or parents in arranging an adoption placement. (23 Pa.C.S. § 2102)]

1. List name and address of INTERMEDIARY:

2. The child proposed to be adopted (ADOPTEE) is:

 a)  Name:

 b)  Age, place and date of birth:

 c)  Sex: Male (   ) Female (   )

 d)  Religious affiliation:

 e)  Racial background:

3. Placement of ADOPTEE with adopting parent(s):

 a)  When:

 b)  Where:

4. Parents of ADOPTEE:

 a)  BIRTH MOTHER:

  (1)  Name:

  (2)  Age and date of birth:

  (3)  Racial background:

  (4)  Marital status as of the time of birth of ADOPTEE:

   (A)  If married, state name of husband:

  (5)  Marital status during one year prior to the birth of ADOPTEE:

  (6)  Religious affiliation:

 b)  BIRTH FATHER:

  (1)  Name:

  (2)  Age and date of birth:

  (3)  Racial background:

  (4)  Marital status as of the time of birth of ADOPTEE:

   (A)  If married, state name of wife:

  (5)  Marital status during one year prior to the birth of ADOPTEE:

  (6)  Religious affiliation:

5. Identify all proceedings wherein any of ADOPTEE's parents' (or putative father's) parental rights and/or duties were terminated. [If termination occurred in a court other than the court in which the petition for adoption will be filed, attach a certified copy of the ORDER (23 Pa.C.S. § 2534(3))].

6. List residence of parent(s) of ADOPTEE if their parental rights have not been terminated:

7. Explain what consents required by 23 Pa.C.S. § 2711 are applicable in this Adoption. Attach the applicable consents as Exhibits to this report. (If the original consent is required as a part of another report or petition, a copy may be attached in lieu of the original.) [23 Pa.C.S. § 2534(2)]

8. List an itemized accounting of monies 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. List full description and statement of value of all property owned or possessed by the ADOPTEE:

10. Has any provision of any statute regulating the interstate placement of children been violated with respect to the placement of the child?

11. Attach a birth certificate or certification of registration of birth. [23 Pa.C.S.A. § 2534(1)] If no birth certificate or certification of registration of birth can be obtained, state why. [See 23 Pa.C.S.A. § 2701(9)]

12. Has medical history information been obtained? If it has not been, please set forth the reason therefor. (See 23 Pa.C.S. § 2533).

_________________
Intermediary    

COMMONWEALTH OF PENNSYLVANIA	:
	:	ss
COUNTY OF WESTMORELAND	:

 The above named INTERMEDIARY, being duly sworn according to law deposes and says that the facts set forth in the above Intermediary Report are true and correct to the best of his/her knowledge, information and belief.

_________________
[Signature of Intermediary]   

Sworn to and subscribed

before me this ______ day

_________________, 20______

_________________
  (Signature of Notary)

  (SEAL OF NOTARY)

(Alternative Method for Verification)

 I the above named Intermediary do verify that the statements contained in the Intermediary's Report are true and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsifications to authorities. (The maximum penalty for such violation is a period of incarceration up to two years and a $5,000 fine.)

Date _________________

___________________________

[Pa.B. Doc. No. 23-393. Filed for public inspection March 24, 2023, 9:00 a.m.]

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