Appendix Form B

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Appendix Form B

IN THE ORPHAN'S COURT DIVISION
COURT OF COMMON PLEAS OF
ALLEGHENY COUNTY, PENNSYLVANIA

In Re Adoption of )
)
) No.             of

REPORT OF INTERMEDIARY

The name of the Intermediary
Address

Proposed Adoptee:
Name
Sex               Age            Date of Birth
Place of Birth
Racial Background
Religious Affiliation


Date of Placement of Proposed Adoptee with Adopting Parents)

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:


Birth Father
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:


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:

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.

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:

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:

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.

Set forth a full description and statement of the value of all property owned or possessed by the adoptee.

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.

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:

The medical history information on the birth parents 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

County of Allegheny )
) SS:
)

     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,                    ,                  ,               .



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IN THE ORPHAN'S COURT DIVISION COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
In Re Adoption of	) ) ) No. of
REPORT OF INTERMEDIARY
The name of the Intermediary Address Proposed Adoptee: Name Sex Age Date of Birth Place of Birth Racial Background Religious Affiliation Date of Placement of Proposed Adoptee with Adopting Parents) 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: Birth Father 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: 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: 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. 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: 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: 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. Set forth a full description and statement of the value of all property owned or possessed by the adoptee. 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. 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: The medical history information on the birth parents 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 County of Allegheny	) ) SS: )
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, , , .