Adoption Agreement {JD-JM-197}

ADOPTION AGREEMENT JD-JM-197 New 10-12 P.A. 12-82, Sec. 16 C.G.S. § 45a-724 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Address of Court Docket number Name and address of minor child Date of birth Petitioner address (Statutory parent - Department of Children and Families) Phone number Name and address of adopting parent Phone number Name and address of adopting parent Phone number The Department of Children and Families, duly authorized statutory parent of the minor child, who may by law give a child in adoption, gives in adoption the minor child named above to the adopting parent(s) and the adopting parent(s) adopt and receive the minor child as their legal child. The statutory parent giving the minor child in adoption and the adopting parent(s) represent that each is lawfully entitled to enter into this agreement of adoption. Change the name of the minor child to: This agreement of adoption shall take effect upon its approval by an Order of the Superior Court for Juvenile Matters. Signed (Statutory parent) Date signed Signed (Adopting parent) Date signed Signed (Adopting parent) Date signed Consent of Minor Child I am 12 years old or older and consent to this agreement. Signed (Minor child) Date signed ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. American LegalNet, Inc. www.FormsWorkFlow.com