FORM 19.5 Report of Intermediary

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

REPORT OF INTERMEDIARY

1. Intermediary Name Address

2. Facts as to the child to be adopted:

Name Sex Racial background

Religious affiliation Age

Date and Place of Birth

3. Completed birth certificate attached hereto as Exhibit ``A.'' If not, provide explanation in

Paragraph 13.

4. The date of the placement of the child with the adopting parent or parents. Date

5. Explain intermediary's involvement in child's placement.

6. Facts as to the natural parent(s) of the child:

Mother Name

Father Name

7. Identify proceedings in which any decree of termination of parental rights, or parental rights

and duties, with respect to the child have been entered:

A. As to the Mother B. As to the Father

8. The present or last known residence of the parent or parents of the child, if there has been

no such decree of termination:

A. As to the Mother B. As to the Father

9. A statement that all consents required by Section 2711 (relating to consents necessary to

adoption) are attached hereto as Exhibits ``B'' and ``C,'' or the basis upon which the consents

are not required:

10. An itemized accounting of monies and consideration paid to or received by the intermediary

or by any other person to the knowledge of the intermediary by reason of the adoption

placement:

11. A full description and statement of the value of all property owned or possessed by the

child:

12. A statement that no provision of any statute regulating the interstate placement of children

has been violated with respect to the placement of the child:

13. If no birth certificate or certification of registration of birth can be obtained, a statement

of the reason therefore:

14. Medical history information as defined by Section 2102 of the ADOPTION ACT has been

obtained and delivered pursuant to Section 2909 of the ADOPTION ACT.

15. Notice of the filing of this report has been given to the adopting parents as is evidenced

by a true and correct copy of said notice which is attached hereto, made a part hereof, and

marked Exhibit ``D.''

__________________

(Intermediary)

[Verification]