Adoption Data Sheet {JD-JM-196}

ADOPTION DATA SHEET JD-JM-196 New 10-12 P.A. 12-82, Sec. 16 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Address of Court Docket number Name of minor child Date of birth Adoption Data Minor Child Proposed name of minor child after adoption: Given name as shown on Birth Certificate: Child's present address Child's place of birth Parents Name of biological mother Last known address Name of biological father Last known address If mother deceased, place of death Date of death If father deceased, place of death Date of death Court where mother's parental rights terminated Date of termination of parental rights Court where father's parental rights terminated Date of termination of parental rights Statutory parent (Address of main or local office) Court of appointment Date of appointment Adopting Parent(s) Name of adopting parent and address Relationship to child Name of adopting parent and address Relationship to child Place of marriage (If applicable) Date of marriage To the best of my knowledge and belief, there is no other proceeding pending or contemplated in any other court affecting the custody of the minor child to be adopted. If there is such a proceeding, a statement is attached explaining in detail the nature of the proceeding and that the proposed adoption will not conflict with or interfere with such other proceeding. This data is submitted in connection with the application for approval of the Adoption Agreement concerning the minor child and is true to my best knowledge and belief. The representations contained in this Data sheet are made under penalties of false statement by a duly authorized representative of the Department of Children and Families. Signed (Duly authorized representative) Print or type name of person signing at left Subscribed and Sworn to before me: On (Date) Signed (Notary public, Assistant clerk, Commissioner of the Superior Court) American LegalNet, Inc. www.FormsWorkFlow.com