FORM
19.6 Petition for Voluntary Relinquishment
IN THE COURT OF COMMON PLEAS OF
__________________ COUNTY, PENNSYLVANIA
IN RE: : No.
ADOPTION OF
ORDER
AND NOW, to wit, 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 _______________,
at ,
,
Pennsylvania. .
(address)
(city)
(zip-code)
BY THE COURT:
__________________
J.
IN THE COURT OF COMMON PLEAS OF
__________________ COUNTY, PENNSYLVANIA
IN RE: : No.
ADOPTION OF
DECREE
AND NOW, to wit, this
____________ day of __________________, 20______, upon
consideration of the
Petition for Voluntary Relinquishment and after hearing thereon, upon
consideration of the
unconditional consent signed by the natural mother, __________________,
and after the Court's
finding that the averments of the within Petition are true, it is ORDERED
and DECREED that all
parental rights of the natural mother are hereby forever terminated.
[AND, if applicable ]
The putative father
not having been identified, and not having filed an acknowledgement of
paternity pursuant to
Section 8302 or 8303, or the putative father not having filed a Petition for
Voluntary
Relinquishment of his rights pursuant to Section 2501 or 2502 and not having
filed an
acknowledgement of
paternity pursuant to Section 8302 or 8303, and having been given notice of
the termination
hearing and having failed to appear at this hearing for the purpose of
objecting to
the termination of
his parental rights or to file a written objection to the termination with the
Court prior to the
hearing, it is therefore ORDERED and DECREED that all parental rights of
the putative father
are hereby forever terminated.
The custody of
__________________ shall remain with the adult or adults who have signed a
consent to accept
custody of the child and who have filed a Report of Intention to Adopt and
who shall have the
right to proceed with the adoption of said child without further notice to the
natural mother [or
putative father].
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 consideration
of the Petition for
Voluntary Relinquishment of Parental Rights and after hearing thereon, the
parental rights of
__________________ are hereby forever terminated and custody of
__________________ is
hereby awarded to __________________ and
__________________.
BY THE COURT:
__________________
J.
IN THE COURT OF COMMON PLEAS OF
__________________ COUNTY, PENNSYLVANIA
IN RE: : No.
ADOPTION OF
PETITION FOR VOLUNTARY RELINQUISHMENT
OF PARENTAL RIGHTS
TO THE HONORABLE, THE
JUDGES OF THE SAID COURT:
The Petition of
__________________ respectfully represents that:
1. The child, __________________, who was born on __________________
__________________ in
__________________ was placed by __________________
on __________________
with __________________ and has been continuously in their care
and custody since that time.
2. Petitioner is the natural mother of said child and she was born on
__________________ in
__________________.
3. Petitioner
is of the __________________ race and __________________ religion.
4. Petitioner
resides at ___________ _______.
5. Petitioner
executed a Consent to Adoption in accordance with Section 2711 of the Adoption
Act on
__________________. The original Consent is attached hereto and marked as
Exhibit ``A.''
6. Petitioner
desires to relinquish forever all parental rights to __________________, for
the
following reasons:
7. The natural/putative father of the
adoptee is _________________ _________________.
8. The natural/putative father was
born on __________________ in __________________.
9. The natural/putative father's last
known address is __________________
__________________.
10. The natural/putative father is of
the ________________ race and ________________
religion.
11. The natural/putative father
did/did not execute a consent to adoption. (If natural/putative
father did execute
consent, it is attached hereto and marked as Exhibit ``A-1.'')
12. If natural/putative father's
identity has not been revealed, an affidavit executed by the
natural mother
regarding why his identity has not been revealed is attached hereto and marked
as Exhibit ``B.''
13. A ``no claim of paternity''
statement is attached hereto and marked as Exhibit ``C.''
14. Statement
by Parent form executed by Petitioner is attached hereto and marked as
Exhibit ``D.''
15. Consent to Accept Custody executed
by adopting parents is attached hereto and marked
as Exhibit ``E.''
16. The
adoptee is now and has been since __________________ __________________
in the exclusive
possession, custody and care of persons, who, your Petitioner is informed, have
filed a Report of
Intention to Adopt on __________________.
WHEREFORE, Petitioner
prays your Honorable Court for a finding of voluntary relinquishment
and for a Decree of
Termination directing the transfer of the custody of the child to adults
intending to adopt
the child without further consent of or notice to Petitioner.
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