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Voluntary Relinquishment Packet - Pennsylvania
| Voluntary Relinquishment Packet Form. This is a Pennsylvania form and can be used in Orphans Court Westmoreland Local County . |
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IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF (Adoptee's name as on birth certificate) : : : : : No: OF ATTORNEY: NOTICE (Voluntary Relinquishment) TO: A petition has been filed asking the court to put an end to all rights you have to your child The court has set a hearing to consider ending your rights to your child. That hearing will be held in . Courtroom # ________ on the _________ day of ________________________, 20______ at ___________ A.M./P.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. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LAWYER REFERRAL SERVICE WESTMORELAND BAR ASSOCIATION P.O. BOX 565 GREENSBURG, PA 15601 (724) 834-8490 (Name of Attorney) (Address) (Telephone Number) Rev. 12/14/12 1 American LegalNet, Inc. www.FormsWorkFlow.com IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF (Adoptee's name as on birth certificate) : : : : : No: OF ATTORNEY: PETITION FOR VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS PRELIMINARY ORDER (23 Pa.C.S.A. §2501 and §2502) AND NOW, this ________ day of ____________________________, 20_____ to judicially resolve the attached petition it is ORDERED AND DECREED that an evidentiary hearing is set in Courtroom No. ________ for the _________ day of ________________________, 20_____ at _________________ o'clock _____.M. At least ten days written notice of the hearing shall be given to the petitioner and a copy of the notice as specifically set forth in 23 Pa.C.S.A. § 2503(b) shall be served upon the parent(s) or guardian of the petitioner who has not reached 18 years of age. If only one birth parent is the petitioner, such notice shall be given upon the other parent. If the petition seeks to terminate parental rights of putative father pursuant to 23 Pa.C.S.A. § 2503(b)(3), (d), such notice as specifically set forth therein shall be provided to putative father. Method of providing notice shall conform to Pennsylvania Supreme Court Orphans' Court Rule Nos. 5.1 and 15.6. "Affidavit of Service" relative to all notices shall be filed at least 10 days before the evidentiary hearing to allow the court time to review. BY THE COURT: _______________________________________________ J. ATTEST: _________________________________ Rev. 12/14/12 2 American LegalNet, Inc. www.FormsWorkFlow.com IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF (ADOPTEE's name as on birth certificate) : : : : : No: Attorney: OF PETITION FOR VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS (23 Pa.C.S.A. §2501 and §2502) RELINQUISHMENT TO: "X" the one that applies. To Agency (23 Pa.C.S.A. § 2501) To Adult(s) intending to adopt (23 Pa.C.S.A. § 2502) RELINQUISHMENT BY: "X" those that apply. BIRTH MOTHER. BIRTH FATHER. PUTATIVE FATHER. TO THE HONORABLE, THE JUDGE OF SAID COURT: The Petition of 1. ADOPTEE: a) b) c) d) e) Rev. 12/14/12 . [Names of Relinquishing Parent(s)] List name as appears on birth certificate: Age: Date of birth: Birthplace: Sex: Male ( ) Female ( ) 3 American LegalNet, Inc. www.FormsWorkFlow.com f) g) h) i) Present address: Religious affiliation: Racial background: Who has custody of ADOPTEE and since when: 2. BIRTH MOTHER: a) b) c) d) e) f) Name: Maiden name: Age and date of birth: Birthplace: Present address: Present marital status: Married If married, state: (1) (2) (3) g) Date: Place: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) If yes, name of spouse: h) If ADOPTEE was born out of wedlock, do you intend to marry the birth father? [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(7) and 15.3(a)] No i) Were you married one year prior to the birth of ADOPTEE? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) (2) If yes, name of spouse: If this marriage ended, state how and when: j) The last known address of ADOPTEE's BIRTH FATHER: Rev. 12/14/12 4 American LegalNet, Inc. www.FormsWorkFlow.com k) List the names of all other husbands of BIRTH MOTHER: [PA Orphans' Court Rule 15.3(a)] l) What is your employment? m) n) o) Religious affiliation: Racial background: Are you voluntarily relinquishing your parental rights? Yes (1) If yes, state reasons for seeking relinquishment: [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(8) and 15.3(a)] (2) (3) Is your consent to the adoption attached? Yes THE PARENT RELINQUISHING PARENTAL RIGHTS MUST PERSONALLY APPEAR IN COURT AT THE VOLUNTARY RELINQUISHMENT HEARING. [23 Pa.C.S.A. § 2503] (4) The BIRTH MOTHER has executed this petition voluntarily to promote what the BIRTH MOTHER believes to be in her best interest and the ADOPTEE's best interest. [Pennsylvania Supreme Court Orphans' Court Rules Nos. 15.2(a)(9) and 15.3(a)] 3. BIRTH FATHER: a) b) c) d) e) Name: Age and date of birth: Birthplace: Present address: Present marital status: Married If married, state: (1) (2) (3) f) Date: Place: Name of spouse: Were you married when ADOPTEE was born? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) If yes, name of spouse: Rev. 12/14/12 5 American LegalNet, Inc. www.FormsWorkFlow.com g) If ADOPTEE was born out of wedlock, do you intend to marry the birth mother? [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(7) and 15.3(a)] No h) Were you married one year prior to the birth of ADOPTEE? [Pennsylvania Supreme Court Orphans' Court Rule No. 15.3(a)] Yes (1) (2) If yes, name of spouse: If this marriage ended, state how and when: i) The last known address of ADOPTEE's BIRTH MOTHER: j) What is your employment? k) l) m) Religious affiliation: Racial background: Are you voluntarily relinquishing your parental rights? Yes (1) If yes, state reasons for seeking relinquishment: [Pennsylvania Supreme Court Orphans' Court Rules 15.2(a)(8) and 15.3(a)] (2) (3) Is your consent to the adoption attached? Yes THE PARENT RELINQUISHING PARENTAL RIGHTS MUST PERSONALLY
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