FORM 19.8 Petition to Confirm Consent

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. That all parental rights and duties of __________________, the parent of

__________________, are hereby terminated.

2. That the custody of _________________ is hereby transferred to __________________.

3. That __________________, shall from the date of this Decree have full authority to give

consent to the adoption of __________________ without the consent of, or notification to

__________________.

BY THE COURT:

__________________

J.

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

PETITION TO CONFIRM CONSENT

TO THE HONORABLE, THE JUDGES OF THE SAID COURT:

1. The adoptee, __________________, who was born on __________________, in

__________________, was placed by __________________ (intermediary) on

__________________ with __________________ and has been continuously in their

custody since that time.

2. The natural mother of the adoptee is __________________.

3. The natural mother was born on __________________ in __________________.

4. The natural mother's last known address is _________________ _________________.

5. The natural mother is of the __________________ race and _________________

religion.

6. The natural mother was married/unmarried at the time of the birth of the adoptee.

7. The natural mother 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.''

8. The circumstances surrounding the signing of the attached Consent are as follows:

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

10. The natural/putative father was born on __________________ in _________________.

11. The natural/putative father's last known address is __________________.

12. The natural/putative father is of the _________________ race and ________________

religion.

13. The natural/putative father was married/unmarried at the time of the birth of the adoptee.

14. The natural/putative father did/did not execute a Consent to Adoption. (If natural/putative

father did consent, it is attached hereto and marked as Exhibit ``A-1.'')

15. 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.''

16. A ``no claim of paternity'' statement is attached and marked hereto as Exhibit ``C.''

17. Statement by Parent form executed by natural parent(s) is attached hereto and marked as

Exhibit ``D.''

18. A period in excess of forty (40) days subsequent to the execution of the Consent has

expired and the natural parent has failed to proceed with a Petition for Voluntary

Relinquishment.

19. The Report of Intention to Adopt was filed on __________________.

20. The Report of Intermediary was filed on __________________.

21. Consent to Accept Custody executed by adopting parents is attached hereto and marked

as Exhibit ``E.''

WHEREFORE, your Petitioner requests this Honorable Court to hold a hearing to confirm the

intention of the natural parent to voluntarily relinquish his/her parental rights and duties to

__________________ as evidenced by the Consent to the adoption and to grant a Decree

of Termination of parental rights and duties.

By:

__________________

Intermediary

[Verification]