Fill and Sign the District of Columbia Adoption Form

SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT DOMESTIC RELATIONS BRANCH – ADOPTION EX PARTE IN THE MATTER OF ) ) THE PETITION OF ) ) [Petitioners' Initials] ) Adoption Case No. A- ) ) FOR ADOPTION OF MINOR CHILD. ) PETITION FOR ADOPTION The Petitioner(s) in this case is/are [name(s) of petitioner(s)] . The Petitioner(s) represent(s) the following to this Court: 1. That this Court has jurisdiction under the provision of D.C. Code § 16-301, et. seq. in that: [choose as applicable] (The Petitioner(s) is/are legal resident(s) of the District of Columbia and has/have been for (xxx months/years) .) (The Petitioner(s) has/have resided in the District of Columbia since (date) , which is at least one year next preceding the filing of the petition.) (The prospective adoptee, (name of child) , is in the legal care, custody, or control of [the Child and Family Services Agency] [or name of other agency] , a child-placing agency licensed by the District of Columbia.) 2. The Petitioner(s) (is/are/are not) married. They were married on (date) . (If the Petitioners are not married, state the nature of their relationship.) 3. The Petitioner(s) reside(s) at (address) . 4. The first Petitioner, (name) , was born on (date) and is (age) . This Petitioner is (race) and is a member of the [name of religion] religion. 5. The first Petitioner, (name) , is employed by (name of employer) in the position of [job title] . 6. The second Petitioner, (name) , was born on (dob) and is (age) . This Petitioner is (race) and is a member of the [name of religion] religion. 7. The second Petitioner, (name) , is employed by (name of employer) in the position of [job title] . 8. The prospective adoptee is a young boy/girl , who is (age) years old, was born on (dob) in (place) . The prospective adoptee is (race) and a member of the [name of religion] religion. 9. The prospective adoptee is the Petitioner’(s)’ (relationship to the Petioners) . 10. [choose as applicable] (The Petitioner(s) is/are (not) requesting an adoption subsidy.) (An adoption subsidy agreement has (not) been entered into prior to the filing of this Petition. The status of the subsidy agreement is (status) .) (The prospective adoptee will (not) qualify for an adoption subsidy as the prospective adoptee is (age) years old and       .) 11. The Petitioner(s) has/have (not) received the complete medical, social, or background information on the prospective adoptee. 12. On information and belief, the prospective adoptee’s birth mother is (name of mother) . Her last known address is (address) . Ms. (name) is (race) and a member of the [name of religion] religion. [Alternatively:] (The birth mother’s identity and/or location is unknown and the following efforts have been made to obtain this information: [detail efforts, if any] .) 2 13. On information and belief, the prospective adoptee’s birth father is (name of father) . His last known address is (address) . Mr. (name) is (race) and a member of the [name of religion] religion. [Alternatively:] (The birth father’s identity and/or location is unknown and the following efforts have been made to obtain this information: [detail efforts, if any] .) 14. [choose as applicable] (The prospective adoptee was placed in the care of the Petitioner(s) on (date) (The prospective adoptee was placed in the Petitioner’(s’) care on (date) by Child and Family Services Agency.) (The prospective adoptee is not residing with the Petitioner because: [state reasons] .) 15. [choose as applicable] (There is/are (no) executed original written consent(s) signed by (mother/father/guardian) .) (There is/are (no) relinquishment(s) of parental rights signed by the biological parent(s).) (There is/are (no) order(s) terminating parental rights by a court of competent jurisdiction.) (There is (not) an affidavit by the putative father denying paternity and/or an affidavit by the birth mother that the birth father is unknown.) 16. The name and address of the agency responsible for securing any required consent or relinquishment of birth parent(s) is (name of agency) . 17. The name and address of the birth parent(s), who have not executed a consent is as follows:       . A consent has not been executed because . 18. The Interstate Compact on the Placement of Children (ICPC), D.C. Code Ann. § 4-1421 et. seq. (2005), is (not) applicable to this adoption due to the fact that [state whether or not petitioners reside in a different state than the adoptee . (Approval has (not) been received prior to the filing of this petition.) ( Rule requires copy of approval if received .) 3 19. [choose as applicable] (The Indian Child Welfare Act (Title 25 U.S.C. Sec. 1901 et. seq.) is not applicable to this adoption.) (The Indian Child Welfare Act (Title 25 U.S.C. Sec. 1901 et. seq.) is applicable to this adoption and there has (not) been compliance with the Act.) 20. [choose as applicable] (The prospective adoptee has been the subject of a neglect case, N-       . Judge (name) is assigned to hear periodic neglect reviews in this matter.) (Other court actions involving the prospective adoptee, which have been initiated or pending within the prior five years are       .) (There are no/no other court actions involving the prospective adoptee, which have been initiated or pending within the prior five years.) 21. During the past 10 years, the Petitioner(s) has/have not been a party in a personal capacity in any criminal, civil, or domestic matters, except that Petitioner(s) was/were made a party in the adoptee’s neglect case and [any other matters] . 22. The combined assets of the prospective adoptee do not exceed $3,000.00. ( If incorrect, itemize all assets.) 23. The prospective adoptee is physically, mentally, and otherwise suitable for adoption by the Petitioner(s). 24. The Petitioner(s) is/are fit and able to give the prospective adoptee a proper home and education. 25. The adoption is in the best interest of the prospective adoptee. 26. The Petitioner(s) desire(s) to have conferred upon the prospective adoptee the same status the prospective adoptee would have if the Petitioner(s) was/were the prospective adoptee’s natural parent(s). WHEREFORE , the Petitioner(s) pray(s): 4 1. That an interlocutory/final decree of adoption be entered establishing the relationship of parent and child for all purposes between the Petitioner(s) and the prospective adoptee. 2. [choose as applicable] (That the name of the prospective adoptee be changed to (new name) .) (That the name of the prospective adoptee shall remain (old name) .) 3. That this Court issue an order of reference with a copy of the Petition attached to be served upon Child and Family Services Agency for the purpose of verifying the allegations contained in the Petition. A report is to be made to the Court within 90 days regarding the advisability of the proposed adoption. 4. That the Court waive the requirement of a written consent by the biological (mother) (father) (parents) if that person(s) after such notice as the Court directs, cannot be located, or has abandoned the prospective adoptee and voluntarily failed to contribute to his/her support for a period of at least six months next preceding the date of the filing of the petition. 5. That the Court waive he requirement of a written consent by the biological (mother) (father) (parents) if the Court finds pursuant to D.C. Code § 16-304 that the consent or consents are withheld contrary to the best interest of the child. 6. For such other and further relief as may seem just and proper to the Court. , 2005 _______________________________ Date Signature of Petitioner , 2005 ______________________________ Date Signature of Petitioner 5 DISTRICT OF COLUMBIA, ss:       (and       ) Petitioner(s), being first sworn, testify that (he/she/they) have read the Petition for Adoption and understand its terms and believe that the statements contained in this Petition are true. Subscribed and sworn to before me this       day of       . 200       . ____________________________________ Deputy Clerk/ Notary Public ____________________________________ (Petitioner's Counsel's signature) (Petitioner's Counsel's) (Petitioner's Counsel's Office Address) (Petitioner's Counsel's Telephone No.) (Petitioner's Counsel's Fax No., if any) ( Petitioner's Counsel's D.C. Bar No.) 6