STATE OF WISCONSIN, CIRCUIT COURT, IN THE INTEREST OF COUNTY For Official Use Petition for Adoptive Placement a person under the age of 18. Case No. Date of Birth UNDER OATH, I STATE THAT: 1. a. The child was born on the date indicated above and resides at: b. The child is due to be born about 2. The birth mother resides at 3. The birth father resides at 4. The proposed adoptive mother resides at 5. The proposed adoptive father resides at 6. (Person/agency) 7. The report of financial, medical and legal arrangements is attached. 8. The placement is in a licensed foster home. 9. The Petition for Termination of Parental Rights accompanies this petition. 10. a. The child is not subject to the federal Indian Child Welfare Act. b. The child is subject to the federal Indian Child Welfare Act, and: 1. Indian tribe's name and address: 2. Indian custodian's name and address: (if applicable) 3. Placement has been made in accordance with the order of preference set forth in the Indian Child Welfare Act. OR There is good cause to depart from the order of placement preference in the Indian Child Welfare Act: , age , . , age , . , age , . , age , . arranged placement of the child. . Subscribed and sworn to before me on Petitioner Notary Public, State of Wisconsin Name Printed or Typed My commission expires: Petitioner Distribution: 1. Court-Original 2. Parties 3. Tribe (if any) Name Printed or Typed Date JC-1640, 04/09 Petition for Adoptive Placement §48.837, Wisconsin Statutes; 25 U.S.C. §1915. American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material.