Fill and Sign the Petition Kinship Form

IN THE ___________ COURT OF ___________ (County) , _______________ (State) IN THE MATTER OF THE PETITION OF: _________________________________ (Name of person(s) seeking to adopt) Cause No.____________ FOR THE ADOPTION OF A CHILD Petition for Kinship Adoption The Petitioner _________________ (Name of Petitioner) , being desirous of adopting a child so as to make said child for all intents and purposes the legal child of Petitioner and to render him capable of inheriting Petitioner’s estate, states the following facts: 1. The Petitioner is the child’s: [ ] Aunt [ ] Uncle [ ] Sister [ ] Brother [ ] Half-Sibling [ ] First Cousin [ ] Grandparent 2. Information about the Petitioner: Petitioner’s Full Name _____________________________________________  Place of Birth: ____________________________________________________  Race: _________________  Date of Birth: __________________________  Current Mailing Address: ____________________________________________  City & Zip Code:____________________________________________________  Cell #:_____________Work Phone #:____________ Home Phone #:____________  Occupation: ________________________________________________________  Length of Residence in ______________ (Name of State) : __________________  Place of residence at the time of birth of the child: ___________________________ _______________________________ (street address, city, state, zip code) . 3. Date of Marriage: __________________. As shown by her signature hereon, Petitioner’s wife ________________ (Name of Wife) , has, and does hereby, join in this Petition. 4. Venue is proper in this matter because the Petitioner resides in the County of ___________________ (Name of County) . 5. On ______________ (date) , the Petitioner consulted with the appropriate local County Department of Social Services concerning the possible eligibility of the Petitioner and the child for temporary assistance for needy families (TANF), Medicaid, subsidized adoption and other services or public assistance administered by the County Department of Social Services. 6. The Petitioner has attached as Exhibit A a current fingerprint-based criminal history records check as required by ___________________ (cite state statute) . 7. The Petitioner has attached as Exhibit B the background check as required by ____________________ (cite state statute) . 8. Petitioner has never been convicted of a felony or misdemeanor in any of the following areas, with the exception of the felony or misdemeanor checked and identified as follows:. 1  Child abuse or neglect on _______________ (date) . [ ] Felony [ ] Misdemeanor  Spousal abuse on _________________ (date) . [ ] Felony [ ] Misdemeanor  Any crime against a child on ________________ (date) . [ ] Felony [ ] Misdemeanor  Any crime, the underlying factual basis of which has been found by the Court to include an act of domestic violence on ________________ (date) . [ ] Felony [ ] Misdemeanor  Violation of a Protection/Restraining Order on _________________ (date) . [ ] Felony [ ] Misdemeanor  Any crime involving violence, rape, sexual assault, or homicide on ______________ (date) . [ ] Felony [ ] Misdemeanor  Any felony involving physical assault or battery on _______________ (date) . [ ] Felony [ ] Misdemeanor  Any felony drug-related conviction within the past five years, at a minimum on ________________ (date) . [ ] Felony [ ] Misdemeanor 9. Identify all children of the Petitioner(s) (both natural and adopted and both living and deceased).  Full Name of Child: _________________________________________________  Full Name of Child: _________________________________________________  Full Name of Child: _________________________________________________  Full Name of Child: _________________________________________________  Full Name of Child: _________________________________________________ 10. Facts concerning the child to be adopted (excluding facts if placement is by an agency or Department of Social Services.) A. Date of Birth: _________ Full Name: ___________________________. _ B. Relationship of child to Petitioner, if any: ______________________. C. Place of Birth: __________________________________________. D. Place of Residence: ____________________________________. 11. The child [ ] is [ ] is not a member or eligible to be a member of an Indian tribe as defined by the Indian Welfare Act. If applicable, the name of the tribe is: ___________________ and notice of this Petition has been provided to the parent or Indian custodian of the child and to the tribal agent of the tribe, as required by ___________________ (cite statute) . 12. [ ] Reasonable efforts have been made to send notice to the identified persons as follows: ______________________________________________________, and the postal receipts are attached to this Petition, indicating that notice was properly sent. If the postal receipts have not been returned at the time of filing, the postal receipts or copies shall be filed with the Court within ten days of the filing of this Petition. 13. The child has been in the care and custody of Petitioner since ______________ (date) . 14. The legal custody of the child is with _______________ (Name) . 15. A f ull description of the property of the child, if any is as follows: ____________ ________________________________________________________________ 16. The n ame and address of the Guardian(s) of the child and estate of the child, if any, that have been appointed is/are: ___ ___________________________________________ __________________________________________________________________________________ 17. A certified copy of the Court orders granting [ ] legal guardianship or [ ] allocation of parental responsibilities (decision-making and parenting time) is attached hereto and incorporated herein by reference. 18. Information about the Birth Parents of the Child: A. Full name of birth father: _______________________, who resides at ______________________________________________________ (street address, city, state, zip code) . B. Full name of birth mother_____________________, who resides at ________________________________________________________ (street address, city, state, zip code) . 19. The written consent(s) of the parent(s) [ ] is/are attached, or [ ] is/are not attached. 20. The child will not be the subject of a pending dependency and neglect action when the adoption is heard. 21. If parental rights are relinquished, are terminated, or are being terminated in this action pursuant to ___________________ (cite state statutes) , or parent is deceased, state details: ______________________________________________________________ ______________________________________________________________ 22. Wherefore, the Petitioner prays that a Decree of Adoption be entered herein declaring said child to be the child of Petitioner and that the name of said child be changed to: ________________________ (state full name) and that said child shall be entitled to all of the rights and privileges and be subject to all of the obligations now conferred and imposed by law. Verification and Acknowledgement I swear/affirm under oath that I have read the foregoing Petition and that the statements set forth herein are true and correct to the best of my knowledge. ___________________________ ________________________________ (Printed Name of Petitioner) (Printed Name of Attorney for Petitioner) ___________________________ _____________________________ (Signature of Petitioner) (Signature of Attorney for Petitioner) _________________________________ (Printed Name of Petitioner’s Wife) _________________________________ (Signature of Petitioner’s Wife) STATE OF ____________________ COUNTY OF _______________________ Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named ____________________ (Name of Petitioner) and ______________________ (Name of Petitioner’s Wife) who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing Petition are true and correct as therein stated. ________________________ _________________________________ (Printed Name of Petitioner) (Printed Name of Petitioner’s Wife) ________________________ _________________________________ (Signature of Petitioner) (Signature of Petitioner’s Wife) SWORN to and subscribed before me, this the ______________ (date) . _________________________________ Notary Public My Commission Expires: ___________________