Report Of Intention To Adopt

IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PENNSYLVANIA IN RE: ADOPTION OF : : : : : : No: OF (Adoptee's name as on birth certificate) ATTORNEY: REPORT OF INTENTION TO ADOPT (23 Pa.C.S.A. § 2531) TO THE HONORABLE, THE JUDGES OF SAID COURT: The report of 1. 2. 3. the proposed adoptive parents, respectfully represents: , are residents of County, and their address is . That the proposed adoptive parents, Their religious affiliation is . The proposed adoptive parents have possession or physical care of with the intention of adopting such child. , a minor child, for the purpose and 4. The child proposed to be adopted is: Sex: Male ( Age: Religious Affiliation: ) Female ( ) Born at: Born on : Race: 5. The name and address of the Intermediary (if any) from which the proposed adoptive parents received the child is: Name Address 6. If the child was not received through an Intermediary: The birth father of the child proposed to be adopted is: Name Address Religious Affiliation Rev. 12/26/06 1 American LegalNet, Inc. www.FormsWorkflow.com The birth mother of the child proposed to be adopted is: Name Address Religious Affiliation 7. An itemized accounting of all monies and consideration paid or to be paid to the Intermediary is as follows: 8. The parent(s) whose parental rights are to be terminated (have) (have not) received counseling with respect to the termination and the alternatives thereto. If counseling was received, it was provided on the following dates: and the name and address of the counselor or agency which provided the counseling is: Name Address 9. The date and circumstances surrounding the proposed adoptive parents receiving or retaining custody or physical care of the child proposed to be adopted are: 10. 11. The date on which the pre-placement investigation was concluded is A copy of the pre-placement report is attached hereto. . I ACKNOWLEDGE THAT I HAVE BEEN ADVISED OR KNOW AND UNDERSTAND THAT THE BIRTH FATHER OR PUTATIVE FATHER MAY REVOKE THE CONSENT TO THE ADOPTION OF THIS CHILD WITHIN 30 DAYS AFTER THE LATER OF THE BIRTH OF THE CHILD OR THE DATE HE HAS EXECUTED THE CONSENT TO AN ADOPTION AND THAT THE BIRTH MOTHER MAY REVOKE THE CONSENT TO AN ADOPTION OF THIS CHILD WITHIN 30 DAYS AFTER THE DATE SHE HAS EXECUTED THE CONSENT. Date: ________________________________ _____________________________________________ _____________________________________________ Adoptive Parents Rev. 12/26/06 2 American LegalNet, Inc. www.FormsWorkflow.com