FORM 19.9 Petition for Involuntary Termination

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

ORDER

AND NOW, this ____________ day of __________________, 20______, it is ORDERED

and DECREED that the within Petition be heard on the day of ____________, 20______, at

_____ o'clock, in Room _______, , Pennsylvania.

(address) (city)

BY THE COURT:

__________________

J.

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

DECREE

AND NOW, this ____________ day of __________________, 20______, upon hearing of

the within Petition, and upon motion of __________________, Attorney for the Petitioner, it

appearing that there is no legal objection to the granting of the prayer of the said Petition, is is

ORDERED and DECREED:

1. The parental rights of __________________ are hereby terminated.

2. The Petitioners are awarded custody of __________________.

BY THE COURT:

__________________

J.

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

PETITION FOR INVOLUNTARY TERMINATION

TO THE HONORABLE, THE JUDGES OF THE SAID COURT:

The Petition of __________________ repectfully represents:

1. Petitioner is __________________ years of age, having been born on _______________

in __________________.

2. Petitioner resides at __________________.

3. Petitioner's relationship to the adoptee is that of __________________.

4. Petitioner married __________________, a co-petitioner in the adoption proceedings, on

__________________ in __________________.

5. The adoptee is a minor, having been born on ________________ in _________________.

6. Petitioner has had custody of the adoptee since ________________ ________________.

[OR]

[6. Petitioner and her husband have had custody of the adoptee since __________________.]

7. The natural/putative father of the adoptee is _________________ _________________.

8. The natural/putative father is __________________ years of age and was born on

__________________ in __________________.

9. The natural/putative father resides at __________________.

10. The natural/putative father has not seen or contacted the adopteee since

__________________.

11. The natural/putative father has not contributed towards the support of the adoptee since

__________________.

12. The natural/putative father, by his conduct, has for a period in excess of six (6) months

immediately preceding the filing of this petition, clearly indicated a settled purpose of

relinquishing parental claim to the adoptee. He has refused and failed to perform any parental

duties whatsoever.

WHEREFORE, Petitioner prays your Honorable Court to terminate all rights and duties of

__________________ as parent to __________________ and that custody of the said

adoptee shall remain with Petitioner.

BY:

__________________

J.

VERIFICATION

__________________ hereby verifies that he/she is the Petitioner herein and as such verifies

that the information contained in the within Petition is true and correct to the best of his/her

knowledge, information and belief. This verification is made subject to the penalties of 18

Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Petitioner

__________________

Petitioner