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Fill and Sign the Under Oath I Petition the Court for an Order for Adoption of This Person and State that Form

Fill and Sign the Under Oath I Petition the Court for an Order for Adoption of This Person and State that Form

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JC-1645 , 05/16 Petition for Minor Child Adoption §48.90, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use IN THE MATTER OF THE ADOPTION OF Name Petition for Minor Child Adoption Date of Birth Case No. Under oath, I petition the court for an order for adoption of this person, and state that: 1. I am a relative of the child by blood. the child’s step parent. a proposed adoptive pa rent with whom the child has been placed. My address is . My telephone number is . 2. The parental rights of the mother were terminated and a certified copy of the Order Termina ting Parental Rights is attached. will be terminated on in court. Other: 3. The parental rights of the father were termi nated and a certified copy of the Order Terminating Parental Rights is attached. will be terminated on in court. Other: 4. The guardian is and the consent is attached. consent will be provided prior to the hearing. 5. The child has lived in my home since . 6. The adoption is in the best interests of the child. 7. The child’s name should be changed to . 8. The child is is not may be subject to the federal Indian Child W elfare Act. Tribe/address: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: My commissio n expires: Signature of Petitioner Name Printed or Typed Signature of Petitioner Name Printed or Typed DISTRIBUTION: 1. Original - Court 2. Interested Persons Date

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