FORM 19.4 Report of Intention to Adopt

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

REPORT OF INTENTION TO ADOPT

TO THE HONORABLE, THE JUDGES OF THE SAID COURT:

1. The name(s) and address(es) of the person or persons making this report:

Name_______ ___________ Name_ _________________

Address__________ ________ Address___ _______________

_________ _________

2. The circumstances surrounding such person receiving or retaining custody of physical care

of the child are:

3. The date on which the preplacement investigation was concluded was ________________

[or, the reasons why the preplacement investigation was not concluded are

__________________] and the conditions for interim placement under Section 2530(c) have

[have not] been met. A copy of the preplacement report is attached.

4. Facts as to the child are: Name Sex: Age: Racial Background: Religious Affiliation of the

Child: Date and Place of Birth:

5. Facts as to the intermediary are: Name: Address:

6. As itemized accounting of monies and consideration paid or to be paid to the intermediary is

as follows:

7. State whether the parent or parents whose parental rights are to be terminated have

received counseling with respect to the termination and the alternatives thereto. If the parent(s)

have received counseling, set forth the dates on which counseling was provided and the name

and address of the counselor or agency which provided the counseling.

I/WE ACKNOWLEDGE THAT I/WE HAVE BEEN ADVISED OR KNOW AND

UNDERSTAND THAT THE NATURAL PARENT MAY REVOKE THE CONSENT

TO THE ADOPTION OF THIS CHILD UNTIL A COURT HAS ENTERED A

DECREE TERMINATING THE PARENTAL RIGHTS AND, UNLESS A DECREE

TERMINATING PARENTAL RIGHTS HAS BEEN ENTERED, THE NATURAL

PARENT MAY REVOKE THE CONSENT UNTIL A COURT ENTERS THE

FINAL ADOPTION DECREE.

__________________

Signature

__________________

Signature

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