Fill and Sign the Chapter 5 C Vital Records Administration Nhvrin 4 Form

NHJ B-2185-F P (06 /04/ 2008) Page 1 o f 3 (form erly AOC-082-003 and A OC-082-008) THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H Cour t Na m e: Ca se Nam e: Ca se Num ber: (if k now n) In th e a doption of PETI TIO N FOR AD OPTI ON (RSA 170- B) A CE RT IF IE D COP Y (L ONG FORM) OF THE CHIL D'S B IRTH CERT IFICAT E A ND ALL R EQU IR ED SURRENDERS AND ASSE NTS MUST B E FIL ED W ITH THIS P ETITION . 1. Petition er Na m e Date of Bir th Petition er Na m e Date of Bir th Ma ilin g Address R esidence Tel eph on e How long has peti tione r(s) been r esident( s) of thi s ci ty/tow n? 2. Attor ney Nam e Tel eph on e Ma ilin g Address Bar ID # 3. Marital status of peti tioner (s): Ma rrie d Ci vil Un ion Sing le Other If m arried or ci vil uni on , dat e a nd place of ceremo ny 4. Peti tion er (s) relationshi p to child 5. Date child w as placed i n th e h ome o f th e p etiti oner (s) Per son or ag ency w hich pl ac ed chi ld in t he ho me 6. Peti tion er (s) w ere gran ted c usto dy of th e chi ld on by the Cour t. 7. Is c hild an A mer ican Indian chi ld as defined by the Indi an C hild W elfar e Act ? Y es N o If yes, na me an d addr ess of tribe Is tr ibe r ecognized by the feder al government as el igible for fed eral ser vices or cer tain Al askan nati ve cor por ati ons as de fined in 43 U.S.C . §160 2( c)? Ye s No 8. Child Birth Nam e Date of Bir th P lace of Birth R esidence Ad dr ess Case Name: In the adoption of Case Number: PETITION FOR ADOPTION NHJB-2185-FP (06/04/2008) Page 2 of 3 (formerly AOC-082-003 and AOC-082-008) 9. Birth Mother Name Telephone Mailing address 10. Birth Father Name Telephone Mailing address 11. Are there any pending guardianship, juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimization, custody or other proceedings affecting this child or the proposed adoptive parents of this child? Yes No If yes, attach a separate sheet identifying and explaining each. The petitioners declare that they have the facilities and resources suitable to provide for the nurture and care of the minor adoptee, and that it is the desire of the petitioners to establish the relationship of parent and child with the adoptee. Therefore, the petitioners ask that this adoption be decreed and that the name of the child be changed to Date Petitioner Signature (Must be signed in presence of notarial officer.) Date Petitioner Signature (Must be signed in presence of notarial officer.) State of , County of This instrument was acknowledged before me on by Date Petitioner(s) My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title Case Name: In the adoption of Case Number: PETITION FOR ADOPTION NHJB-2185-FP (06/04/2008) Page 3 of 3 (formerly AOC-082-003 and AOC-082-008) ASSENTS CHILD'S ASSENT I am the child mentioned in this petition, am 14 years of age or older, and give my assent to the adoption and the change of my name as described in this form. Date Child Signature Signed in the presence of Presiding Judge ASSENT OF PETITIONER’S SPOUSE WH O IS PARENT OF ADOPTEE I am the spouse of the petitioner and parent of the adoptee, and will maintain all those parental rights along with the petitioner. I give my assent to the petitioner’s adoption of the child named in this petition and to the change of the child’s name as described in this petition. Date Parent Signature ASSENT OF PETITIONER’S SPOUSE TO ADOPTION OF ADULT I am the spouse of the petitioner, and assent to the petitioner’s adoption of the adult child named in this petition. Date Spouse Signature A SSENT OF ADOPTEE’S SPOUSE I am the spouse of the adoptee, and I assent to this adoption. Date Spouse Signature DECREE Petition for adoption is granted. Petition for adoption is granted on an interlocutory basis. (See separate Interlocutory Decree of Adoption.) Date Judge