Fill and Sign the Request for Prospective Adoptive Parent Designation Notice and Order California Form

Clerk stamps date here when form is filed. Request for Prospective Adoptive Parent Designation, Notice, and Order After filling out this form, bring it to the clerk of the court. If you want to keep an address or telephone number confidential, fill out form JV-322, Confidential Information—Prospective Adoptive Parent, and do not write the address or phone number on this form. 1 Information about the person or persons you want to be designated as prospective adoptive parents: a. Name: ––––– Fill in court name and street address: b.Name: ––––– Superior Court of California, County of ––––– c. Address: ––––– ––––– ––––– d. Phone number: ––––– ––––– ––––– 2 If you are not a person in 1 , fill out below. ––––– Fill in child's name and date of birth: a. My name: ––––– Child's Name: ––––– b. I am the child child’s attorney other Date of Birth: ––––– (specify role): ––––– Clerk fills in case number when form is filed. c. My address: ––––– Case Number: d. My phone number: ––––– ––––– 3 If you are not the child’s attorney and you know who the child’s attorney is, fill out below. a. Name of child’s attorney’s : ––––– b. Phone number of child’s attorney: ––––– c. Address of child’s attorney: ––––– 4 The child is 10 years of age or older. Child’s phone number: ––––– or Telephone number is confidential 5 The child lived with the person from (date): ––––– to (date): ––––– and from (date): ––––– to the present. In order for the person in 1 to become a prospective adoptive parent, the child must be living with that person now. 6 Date of Welfare and Institutions Code section 366.26 hearing: If a Welfare and Institutions Code section 366.26 hearing has not been set, it is too early to fill out this form. he person in 1 must wait until the section 366.26 hearing is scheduled and parental rights are terminated to be designated as a prospective adoptive parent. 7 The person in 1 is committed to adopting the child. Judicial Council of California, www.courtinfo.ca.gov JV-321, Page 1 of 6 Revised January 1, 2007, Mandatory Form Request for Prospective Adoptive Welfare and Institutions Code, § 366.26(n) Parent Designation, Notice, and Order Cal. Rules of Court, rule 5.726 JV-321 electronic form ã 2005-7 WWW.LawCA.co m Law Publishers Case Number: Child’s name: ––––– ––––– 8 The person in 1 has (check all that apply): a. Applied for an adoptive home study b. Cooperated with an adoptive home study c. Signed an adoptive placement agreement d. Requested de facto parent status e. Been designated by the juvenile court or the licensed adoption agency as the adoptive family f. Discussed a postadoption contact agreement with the social worker, child’s attorney, child’s Court Appointed Special Advocate (CASA) volunteer, adoption agency, or court g. Worked to overcome any impediments that have been identified by the California Department of Social Services or the licensed adoption agency h. Attended any of the classes required of prospective adoptive parents i. Taken other steps toward adopting the child (explain): ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– If you need more space, attach a sheet of paper and write “JV-321, Item 8—Steps Toward Adoption” at the top. Number of pages attached: ––––– I declare under penalty of perjury under the laws of the State of California that the information in items 1 through 8 is true and correct, which means if I lie on this form, I am committing a crime. Date: ––––– ––––– Type or print your name Sign your name ––––– Type or print your name Sign your name Revised January 1, 2007 Request for Prospective Adoptive JV-321, Page 2 of 6 Parent Designation, Notice, and Order Case Number: Child’s name: ––––– ––––– Clerk stamps date here when form is filed. NOTICE 10 Notice of the request for “prospective adoptive parent” designation was given to: a. The adoption agency (name of agency employee notified): (1) Orally, in person, on (date): at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Fill in court name and street address: Phone number: ––––– Superior Court of California, County of (3) By personally delivering copies to the person served on ––––– (date): ––––– at (time) ––––– : ––––– (4) By placing copies in a sealed envelope and depositing ––––– the envelope directly in the U.S. mail with postage paid ––––– at my place of business for same-day collection and ––––– mailing with the U.S. mail, following our ordinary ––––– business practice addressed as follows: ––––– ––––– b. The caregiver (name): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– or Confidential phone number in court file (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– or Confidential address in court file c. The child’s attorney (name): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– Revised January 1, 2007 Request for Prospective Adoptive JV-321, Page 3 of 6 Parent Designation, Notice, and Order Case Number: Child’s name: ––––– ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– d. The Child, if 10 years of age or older (name): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– or Confidential phone number in court file (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– or Confidential address in court file e. The child’s identified Indian tribe, if any (name of tribe and person notified): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– or Confidential phone number in court file (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– f. The child’s Indian custodian, if any (name): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– or Confidential phone number in court file (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– or Confidential address in court file Revised January 1, 2007 Request for Prospective Adoptive JV-321, Page 4 of 6 Parent Designation, Notice, and Order Case Number: Child’s name: ––––– ––––– g. The child’s Court Appointed Special Advocate (CASA) program, if any (name of person notified): ––––– (1) Orally, in person, on (date): ––––– at (time): ––––– (2) Orally, by telephone, on (date): ––––– at (time): ––––– Phone number: ––––– or Confidential phone number in court file (3) By personally delivering copies to the person served on (date): ––––– at (time): ––––– (4) by placing copies in a sealed envelope and depositing the envelope directly in the U.S. mail with postage paid at my place of business for same-day collection and mailing with the U.S. mail, following our ordinary business practice addressed as follows: ––––– ––––– ––––– 11 At the time of notice I was at least 18 years of age and not a party to this matter. I work or am employed in the county where the mailing occurred. My residence or business address is (specify): ––––– ––––– ––––– ––––– 12 I declare under penalty of perjury under the laws of the State of California that the information in items 10 and 11 is true and correct, which means if I lie on this form I am committing a crime. Date: ––––– ––––– Type or print your name Sign your name Revised January 1, 2007 Request for Prospective Adoptive JV-321, Page 5 of 6 Parent Designation, Notice, and Order Case Number: Child’s name: ––––– ––––– 13 This order was made: Clerk stamps date here when form is filed. a. On the court’s own motion b. At the request of (name): ––––– (relationship to the child): ––––– c. The request was made: (1) Orally at the hearing held on (date): ––––– (2) In writing by filing form JV-321, Request for Prospective Adoptive Parent Designation, on (date): ––––– Fill in court name and street address: The court finds and orders: Superior Court of California, County of ––––– 14 The child’s current caregiver or caregivers ––––– (name): ––––– ––––– (name): ––––– ––––– is are designated as the child’s prospective adoptive ––––– parent or parents because: a. The child has lived with the caregiver for at least six months b. The caregiver currently expresses a commitment to adopting the child and c. The caregiver has taken at least one step to facilitate the adoption 15 The child’s current caregiver or caregivers (name): ––––– (name): ––––– does do not qualify as the prospective adoptive parent or parents of the child, and the request for designation as the prospective adoptive parent or parents is denied, because: a. The child has not lived with the caregiver for at least six months b. The caregiver does not currently express a commitment to adopting the child c. The caregiver has not taken any steps to facilitate the adoption d. Other (explain): ––––– ––––– 16 The court thinks that the request for designation as a prospective adoptive parent will be contested or wants more evidence on the request, and orders a hearing on the request. The hearing will be on (date): ––––– at (time): ––––– a.m. p.m. in department ––––– of the superior court located at: ––––– ––––– ––––– Date: ––––– Judge (or Judicial Officer) Revised January 1, 2007 Request for Prospective Adoptive JV-321, Page 6 of 6 Parent Designation, Notice, and Order