Petition To Change Birth Record-Gestational Carrier Acknowledgment Of Gestational Carrier

IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ Petition to Change Birth Record ­ Gestational Carrier ACKNOWLEDGMENT OF GESTATIONAL CARRIER (Filing of Petition) I, [GESTATIONAL CARRIER], hereby ack nowledge t hat on [DATE PETITION FILED], a petition was filed in the Co urt of Common Pleas, Chester County, Pennsylvania (Orphans' Court Divis ion), purs uant to the Penns ylvania Department of Health's " Assisted Conception Birth Registra tion" proc edure, wher eby the petitioners, ___________________________ and ________ ____________________, seek a Decree declaring that they ar e the legal parents of [CHILD' S NAME], to w hom I gave birth on [D/O/B], pursu ant to a gestational surrogacy arrangement. I have no objection to that Petition or to the entry of the Decree sought therein. _________________________ DATE ________________________________ [NAME] American LegalNet, Inc. www.FormsWorkFlow.com