Adoption Petition Form

ADOPTION PETITION FORM

In the , County of , State of .

Petitioner Name: ; Residence Address: ; Date of Birth: .

Co-Petitioner Name: ; Residence Address: ; Date of Birth: .

Recitals

WHEREAS, Petitioner(s) seek to adopt the child identified below and to secure for the child the legal rights, privileges and obligations attendant upon lawful adoption; and

WHEREAS, Petitioner(s) represent that they are residents of the county and state indicated above and that the child’s best interests will be promoted by the adoption and by establishing a permanent parent-child relationship with Petitioner(s); and

WHEREAS, Petitioner(s) have obtained or will obtain the required pre-adoption assessments, background clearances, and, where required, written consents from persons whose consent is necessary; and now therefore,

Now, Therefore

Petitioner(s) hereby petition the court for an order granting the adoption sought herein and for related relief as set forth below.

1. Child to be Adopted

Child's Full Legal Name: ; Child's Date of Birth: ; Sex: .

Place of Birth: ; Current Custodian or Residence: .

2. Jurisdiction and Venue

Petitioner(s) allege that this court has jurisdiction over the subject matter of this petition and over the parties because Petitioner(s) are domiciled or reside in this county and state and because the child has sufficient contacts with this jurisdiction to permit the court to exercise jurisdiction under applicable law.

3. Grounds for Adoption

Petitioner(s) request adoption on the grounds that it is in the best interests of the child. Petitioner(s) state that the child is legally eligible for adoption under applicable statutes by reason of the following facts:

4. Parental Rights and Consents

Mother of the child: . Mother's consent: .

Father of the child: . Father's consent: .

If consent is unavailable, describe attempts to obtain consent or the legal basis for dispensing with consent:

5. Home Study, Background Checks and Fitness

Petitioner(s) represent that a home study has been completed by an authorized entity and that criminal background checks, child abuse registry checks, and any other required screenings have been completed or are pending. Attachments submitted with this petition include proof of home study and clearances.

Home Study Provider: . Date of Home Study: .

6. Relief Requested

Petitioner(s) respectfully request that the court enter an order:

1. Terminating or extinguishing any parental rights as required by law and, where lawful, incorporating any necessary findings;
2. Declaring that the legal relationship of parent and child between Petitioner(s) and the child named above is established;
3. Issuing an amended birth certificate reflecting Petitioner(s) as the child's parent(s); and
4. Granting such other and further relief as the court deems just and proper to effectuate the adoption.

7. Attachments

Petitioner(s) attach and submit the following documents in support of this petition: certified copy of child's birth record; signed consents or documentation of consent being waived; home study report; criminal and abuse clearance reports; medical reports; and any court orders relevant to custody or guardianship.

8. Notices

All notices, pleadings, orders and other communications concerning this petition shall be served upon Petitioner(s) at the addresses provided herein and upon counsel of record if represented.

9. Verification and Certification

I/We, the undersigned Petitioner(s), declare under penalty of perjury under the laws of the State that the statements made in this petition are true and correct to the best of my/our knowledge and belief. Petitioner(s) understand that knowingly making a false statement in this petition may subject the declarant(s) to criminal and civil penalties.

10. Governing Law

This petition and any orders entered hereunder shall be governed by and construed in accordance with the laws of the State in which this court sits.

11. Entire Agreement

This petition, together with the attachments filed in support, constitutes the entire statement of facts and request for relief by Petitioner(s) and supersedes any prior oral or written representations relating to the adoption described herein.

12. Severability

If any provision of this petition is held to be invalid or unenforceable, the remainder of the petition shall remain effective and enforceable to the fullest extent permitted by law.

13. Waiver and Amendments

No waiver of any provision of this petition shall be effective unless in writing signed by the party waiving compliance. Petitioner(s) reserve the right to amend or supplement this petition upon discovery of additional facts or as ordered by the court.

14. Request for Hearing

Petitioner(s) request that the court set this matter for hearing at the court's earliest convenience and enter such orders as necessary to effectuate the adoption after due notice and consideration of the child's best interests.

Oath of Petitioner(s)

State of , County of . I/We swear or affirm under penalty of perjury that the statements contained in this petition are true and correct.

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