FORM 19.15 Statement by Parent

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

IN RE: : No.

ADOPTION OF

STATEMENT BY PARENT

I, __________________, on __________________, voluntarily relinquished parental rights to

my child or was interviewed in the court office.

If in the future my child desires to contact me,

(please check one box only):

[ ] I do wish the information divulged to him/her after he/she becomes 18 years old.

[ ] I do not wish the information divulged to him/her after he/she becomes 18 years old.

__________________

Witness

Signature__________________

Address __________________

__________________

__________________

Telephone __________________