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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                                           and                                               
                              (adoptive father)                                            (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                                                      , petitioner, is              years of age,
                                 (adoptive father)
    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,
                                 (adoptive mother)
    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                                                         
    Attach the original or certified copy of the Petitioner's marriage certificate.
  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)

  1. 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.)
  2. The adoptee's financial or property assets are as follows:
  3. 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.
  4. 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                                 .  And his marital status during one (1) year prior thereto 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                                 .  And his marital status during one (1) year prior thereto was                                  .
  1. 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.
  2. 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.
  3. 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)
  4. That it is the desire of the petitioners that the relationship of parent and child be established between petitioners and the adoptee.
  5. That it is desired that the new name of adoptee be                                 
                                                                                                                
  6. 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).
  7. Attached hereto are consents to adoption given by the adoptee, if over twelve (12) years of age, and the adopting parent's spouse, unless he or she joins in the adoption petition.
  8. 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:
                                             
(Signatures of Petitioners)

 

 

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                                                          ,
                           (full name)                                                                        (address)
have witnessed the execution by,                                                                       ,
                                                                                                                      (birth parent)
of the above Consent to Adoption of                                                                 
                                                                                                                       (adoptee)
on the              day of               ,           .  My relationship to                              
                                                                                                                                  (birth parent)
is                                                 .
                                             
(signature of witness)

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