Fill and Sign the P 455 Affidavit of Reasonable Investigation State of Alaska Form

Page 1 of 5 AS 25.23.080 P- 405 ( 9/17)(cs) Adoption Rule 6 PETITION FOR ADOPTION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the matter of the adoption of ) ) ) ) (child's name after adoption) ) ) DOB: , A Minor Child, ) ) By , ) CASE NO. Petitioner. ) ) ADOPTION PETITION I. Court Information This is the correct court to hear this matter because: does not know the CINA parties and asks the Alaska Court System to send notice. has filed notice to the CINA parties. Proof of notice is attached to this petition. Proof of consent is attached to this petition. There is no open CINA matter for the child, and this location is where: The person(s) seeking to adopt the child resides or is in the military. The child resides at the time of filing. The agency that has care, custody, or control of the child is located. II. Child’s Information a. Child’s current full name (leave blank if an agency adoption) :b. Child’s name after adoption: c. Child was born on , in , . (date) (city) (state or country) d. Child’s current address: e. Number of years child has lived at the above address: f. Name of birth parents, if known: The child has an open Child in Need of Aid (CINA) matter. Case number (if known): . This is the location where the CINA proceedings are pending. While the CINA proceedings are not in this location, the petitioner resides in this district and: AS 25.23.080 Adoption Rule 6 Page 2 of 5 P-4 05 (9/17)(cs) PETITION FOR ADOPTION g. The child has no property of significant value, except: [Includes money in bank accounts, ANCSA Corporation shares, real property, jewelry etc. ] Description of Property Estimated Value h. Does the child qualify as an Indian child? (Child is a member of an Indian tribe; or child is eligible for membership in a tribe and either of the child's biological parents is a member of an Indian tribe.) No. Yes. Fill out P-450, Report of Indian Adoptive Placement. i. To my knowledge and belief, there are are not any other court cases involving this child now pending in a state or tribal court in Alaska or in another state (including tribal courts). Type of Court Case Where Case No., if known III. Petitioner Information a. Name of Adopting Parent(s): b. Marital Status: not married. married . Spouse’s name : . Marriage occurred on , in . (date) (city) (state) c. Mailing address :d. Number of years you have lived in the above city: e. Telephone Number: f. I /we have a place to live and resources suitable to provide for the nurture and care of the child and I/we desire to establish the relationship of parent and child with this child. AS 25.23.080 Adoption Rule 6 Page 3 of 5 P-4 05 (9/17)(cs) PETITION FOR ADOPTION IV. Adoption Information a. What kind of adoption is this? Private agency adoption . Name of Agency: State agency adoption. Name of Agency: Non -Agency/ Independent adoption Relative Nonrelative Stepparent adoptio n b. Is this an adoption of an Indian child? No. Yes. I/we should be the adoptive parent because: I am a member of the child’s extended family. I am another member of the child’s tribe. I am a member of another Indian tribe . I believe there is good cause to deviate from the Indian Child Welfare Act’s adoptive placement preferences. (See 25. U.S.C. 1915(a).) c. Consent. 1.All the following persons whose consent is required by Alaska Statute 25.23.040 have consented to this adoption: The mother of the minor. The father of the minor. T he minor, if the minor is age 10 or older. Any spouse of the child to be adopted. A ny other person who is lawfully entitled to custody of the child or empowered t o consent. Person or agency's name: . Consent forms from each of the above persons accompany this petition. I understand that consent or relinquishment must be signed in a hearing in the presence of a judge or a special master when: the consenting parents are the parents of an Indian child, the consenting parent is a minor, or the consenting child to be adopted is over the age of 10. AS 25.23.080 Page 4 of 5 P-4 05 (9/17)(cs) Adoption Rule 6 PETITION FOR ADOPTION 2. If consent is not required because of a reason recognized in AS 25.23.050, please state the reason. Name of person whose consent Reason is not needed: d. Visitation after the Adoption. AS 25.23.130. 1. The parent consenting to the adoption of the child has requested that he/she/other relative will will not be allowed visitation with the child following the adoption, as specified in that parent's consent/relinquishment. 2. I agree do not agree with this request. e. I believe that this adoption is in the best interests of this child. f. I/we also filed the following: 1. a certified copy of the child's birth certificate (or verification of the birth record ),2. a filled out form VS- 550 1 , Descriptive Information Regarding Biological Parents, 3. a filled-out form VS- 5011 , Report of Adoption, 4. the required consent forms, and 5. t he report of expenditures required by AS 25.23.090 (not required for a stepparent adoption) .[If I am unable to provide any of the above five requirements at the time of filing, my petition will still be accepted by the court, h owever, my petition will be deficient until complete.] g . I /we ask the court to: 1. grant this petition for adoption and declare the child to be my child for all legal purposes, 2. declare that the child will be known from now on by the name shown at the top of page one of this petition, and 3. order that a new birth certificate be issued for the child. yes no 1 VS -550 and VS-501 may be requested from Vital Statistics by email at BVSSpecialServices@alaska.gov ; by phone at (907)465-3162; in person in Juneau at 5441 Commercial Blvd, Juneau, AK; or in person in Anchorage at 3601 C St., Suite 128, Anchorage, AK. AS 25.23.080 Adoption Rule 6 Page 5 of 5 P-4 05 (9/17)(cs) PETITION FOR ADOPTION Verification [DO NOT SIGN YET. This must be signed in front of a clerk of court, notary public, or other person authorized to administer oaths.] I state on oath or affirm that I have read this petition and that all statements made in it are true to the best of my knowledge and belief. Date Signature of Adoptive Parent Date Signature of Adoptive Parent Subscribed and sworn to or affirmed before me at , Alaska on . (date) (SEAL) Clerk of Court, Notary Public, or other person authorized to administer oaths. My commission expires: Certificate of Service [File this petition with the court. If the adoption involves an Indian child, notice must be given to the child’s tribe. Unless this is a stepparent adoption, you must serve a copy of this petition on the Department of Health and Social Services at: Office of Children’s Services Adoption Unit P.O. Box 110630 Juneau, AK 99811- 0630 If this is the adoption of an Indian child, you must also serve a copy of this petition on the relevant tribe.] I certify that on (date) a copy of this petition was mailed hand delivered to [list everyone served and attach extra pages if necessary]: Your signature: