Frank. Cnty. Pa. 39-16

As amended through October 30, 2020

Rule 39-16 - FORMS

(a)Consent of a child over the age of 12. A child over the age of 12 shall consent to his or her adoption and shall sign a consent form in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

CONSENT TO ADOPTION BY ADOPTEE

(Consent of proposed adoptee over 12 years of age)

23 Pa. C.S.A. § 2711(a)(1)

I, [name of adoptee] , the above proposed adoptee, aged [age] , do hereby certify that I have read the petition in the above-captioned matter and fully understand the contents thereof and do hereby, without reservation, give my consent to my adoption by [name of adopting parents] the petitioners in the above-captioned matter.

I have read and understand the above and I am signing it as a free and voluntary act.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this _____day of __________, 20 _____, at ___________.

________________________________

(Signature of Consenter)

Place of execution: _______________________________________________________

WITNESSES:

_________________ ______________________ ______________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

_________________ ______________________ ______________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

STATE OF ______________________

COUNTY OF ____________________

On this, the ______day of ______________, 20__, before me, ________________________________, the undersigned officer, personally appeared __________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

_______________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(b) Consent by biological parent. A biological parent who is not a petitioner in the adoption action shall sign a consent to the adoption of the child in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

CONSENT TO ADOPTION

23 Pa. C.S.A. § 2711(a) and (d)

________________________ ____________ _______________ ____________________

(Name of Consenting Parent) Age (Marital Status) (Relationship to Child)

_____________________

(Name of Other Parent)

I hereby voluntarily and unconditionally consent to the adoption of [name of adoptee], born [date of birth].

I understand that by signing this consent I indicate my intention to permanently give up all rights to this child.

I understand such child will be placed for adoption.

I understand I may revoke this consent to permanently give all rights to this child by placing the revocation in writing and serving it upon the agency or adult to whom the child is relinquished.

If I am the birth father or putative father of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within 30 days after either the birth of the child or my execution of the consent, whichever occurs later, by delivering a written revocation to _____________________________________________________[insert the name and address of the agency coordinating the adoption] or __________________________ ___________________[name and mailing address of attorney representing the individual relinquishing parental rights or prospective adoptive of the child] or the Clerk of Courts for the Orphans Court of the Court of Common Pleas of the 39^th Judicial District, Pennsylvania- Franklin County Branch, 157 Lincoln Way East, Chambersburg, PA 17201.

If I am the birth mother of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within 30 days after executing it by delivering a written revocation to [insert the name and address of the agency coordinating the adoption] or [name and mailing address of attorney representing the individual relinquishing parental rights or prospective adoptive of the child] or the Clerk of Courts for the Orphans Court of the Court of Common Pleas of the 39^th Judicial District, Pennsylvania-Franklin County Branch 157 Lincoln Way East, Chambersburg, PA 17201.

{I acknowledge that the adopting parent(s) name(s) [is][are] . } or

{I hereby certify that this consent is being voluntarily executed without the disclosure of the name or other identifying information of the adopting parent or parents.}

I have read and understand the above and I am signing it as a free and voluntary act.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this _____day of ___________ 20 _____, at ___________.

__________________

(Signature of Consenter)

Place of execution: _______________________________________________________

WITNESSES:

_________________ _______________ _____________________ ________________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

_____________ ________________________ _____________ ___________________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

STATE OF ______________________

COUNTY OF ____________________

On this, the ______day of ______________, 20__, before me, ________________________________, the undersigned officer, personally appeared _______________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within consent to adoption and acknowledged that he executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

__________________________

(signature of notary public)

[Seal]

Title: ___________________________

My commission expires: ___________

I maintain my office in: ____________

(c)Consent of Guardian or Person with Custody: The guardian of the child or person or agency with custody of the child shall sign a consent to the adoption of the child in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

CONSENT TO ADOPTION BY [GUARDIAN][PERSON HAVING CUSTODY OF ADOPTEE]

23 Pa. C.S.A. § 2711(a)(5)

[I] [We], [name of consenter], [being the guardian of][having custody of] [do][does] certify without disclosure of the name or other identification of the adopting parent(s) the [I][we] have read the petition in the above captioned matter and fully understand the contents thereof, and without any undue influence or coercion exerted upon [me][us] by any person, [I][We] willingly and of [my][our] own volition surrender all of [my][our] rights in and to said adoptee, and believing that it will promote [his][her] welfare, give consent to [his][her] adoption.

I have read and understand the above and I am signing it as a free and voluntary act.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this_____day of ___________, 20 _____, at _____.

___________________________

(Signature of Consenter)

Place of execution: _______________________________________________________

WITNESSES:

____________________ _____________________ ______________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

_____________ ___________________ _________________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

STATE OF ______________________

COUNTY OF ____________________

In witness whereof, I hereunto set my hand and official seal.

______________________________

(signature of notary public)

[Seal]

Title: ___________________________

My commission expires: ___________

I maintain my office in: ____________

(d)Consent of spouse or natural parent in a step-parent adoption: The spouse of the adopting parent shall sign a consent to the adoption of the child in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

CONSENT TO ADOPTION BY [ADOPTING PARENT'S SPOUSE](if not joining in petition) [NATURAL PARENT IN STEP-PARENT ADOPTION]

23 Pa. C.S.A. § 2711(a)(2)

I, [name of natural parent], do hereby certify that I am [age] years of age, that I have read the petition in the above captioned matter and fully understand the contents thereof and do hereby, without reservation and without undue influence or coercion exerted upon me by any person, give my consent to the adoption of [name of adoptee] as prayed for in the foregoing petition. [In consenting to this adoption I am hereby retaining for myself all my rights and duties as a natural parent.]

I have read and understand the above and I am signing it as a free and voluntary act.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this _____day of ___________ , 20 _____, at _____.

______________________

(Signature of Consenter)

Place of execution: ______________________________________________________

WITNESSES:

___________________ ____________________ ____________________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

______________________ _________________ _______________

(Name) (Signature) (Relationship to Consenter) (Date)

ADDRESS______________________________________________________________

(street) (town) (state) (zip code)

STATE OF ______________________

COUNTY OF ____________________

In witness whereof, I hereunto set my hand and official seal.

____________________________

(signature of notary public)

[Seal]

Title: ___________________________

My commission expires: ___________

I maintain my office in: ____________

(e)Petition for Involuntary Termination of Parental Rights: The petition for involuntary termination of parental rights provided for in 23 Pa. C.S.A. § 2512(b) and Pa. O.C. Rule 15.4(a) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

PETITION FOR INVOLUNTARY TERMINATION OF PARENTAL RIGHTS

23 Pa. C.S.A. § 2512(b) and Pa. O.C. Rule 15.4(a)

To the Honorable, the Judges of said Court:

The petition of [Name of Petitioner(s)] respectfully represents:

1. That your petitioner, [name of petitioner], [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania][other relation to child], [having its office at][residing at ] [address of petitioner], Franklin County, Pennsylvania, has the care and custody of [name of adoptee], a minor [sex of adoptee] child born [date of birth], in [county of birth] County, Pennsylvania. [Name of adoptee] was born to [name of natural mother] and [name of natural father].

2. That your petitioner, [name of petitioner], is the [intermediary][petitioner] in the above captioned adoption and files this petition under the provisions of Section 2504 of the Adoption Act of 1980, as amended.

3. That the mother of [name of adoptee] is [name of natural mother], her address being [street], [city], Pennsylvania [zip code]; she is [age] years of age, having been born on [date of birth], in [place of birth], Pennsylvania; her race is [racial background]; she is currently [un] married; she was [not] married at the time of the birth of the child and during one year prior thereto; and her religious affiliation is [religion].

4. That [name of adoptee] is a [racial background] male child who is [age] years old, having been born on [date of birth], in Franklin County, Pennsylvania. His religious affiliation is [religion].

5. That the natural father of [name of adoptee] is [name of natural father], whose current address [street], [city], Pennsylvania [zip code]; he is [age] years of age, his date of birth being [date of birth]; his race is [racial background]; he is currently [un] married; he was [not] married at the time of the birth of the child and during one year prior thereto; and his religious affiliation is [religion].

6. The legal grounds for the involuntary termination of parental rights of [name of natural parent] are as follows:

a)23 Pa. C.S. § 2511(a)(1)- The parent by conduct continuing for a period of at least six months immediately preceding the filing of the Petition either has evidenced a settled purpose of relinquishing parental claim to the child or has refused or failed to perform parental duties.

b)23 Pa. C.S. § 2511(a)(2)- The repeated and continued incapacity, abuse, neglect or refusal of the parent has caused the child to be without essential parental care, control or subsistence necessary for his physical or mental well-being and the conditions and causes of the incapacity, abuse, neglect or refusal cannot or will not be remedied by the parent.

c)23 Pa. C.S. § 2511(a)(3)- The parent is the presumptive but not the natural father of the child.

d)23 Pa. C.S. § 2511(a)(4)- The child is in the custody of an agency, having been found under such circumstances that the identity or whereabouts of the parent is unknown and cannot be ascertained by diligent search and the parent does not claim the child within three months after the child is found.

e)23 Pa. C.S. § 2511(a)(5)- The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency for a period of at least six months, the conditions which led to the removal or placement of the child continue to exist, the parent cannot or will not remedy those conditions within a reasonable period of time, the services or assistance reasonably available to the parent are not likely to remedy the conditions which led to the removal or placement of the child within a reasonable period of time and termination of the parental rights would best serve the needs and welfare of the child.

f)23 Pa. C.S. § 2511(a)(6)- In the case of a newborn child, the parent knows or has reason to know of the child's birth, does not reside with the child, has not married the child's other parent, has failed for a period of four months immediately preceding the filing of the petition to make reasonable efforts to maintain substantial and continuing contact with the child and has failed during the same four-month period to provide substantial financial support for the child.

g)23 Pa. C.S. § 2511(a)(7)- The parent is the father of a child who was conceived as a result of a rape or incest.

h)23 Pa. C.S. § 2511(a)(8)- The child has been removed from the care of the parent by the court or under a voluntary agreement with an agency, 12 months or more have elapsed from the date of removal or placement, the conditions which led to the removal or placement of the child continue to exist and termination of parental rights would best serve the needs and welfare of the child.

i) The parent has been convicted of one of the following in which the victim was a child of the parent:

1. An offense under 18 Pa. C.S. Ch. 25 (relating to criminal homicide);

2. A felony under 18 Pa. C.S.§ 2702 (relating to aggravated assault);

3. An offense on another jurisdiction equivalent to an offense in subparagraph (1) or (2); or

4. An attempt, solicitation or conspiracy to commit an offense in subparagraph (1), (2), or (3).

7. The facts which support said grounds for termination are as follows:

8. [Name of natural parent facing termination] is not entitled to the benefits of the Servicemembers Civil Relief Act of 2003 (50 U.S.C. App. 501 et seq.).

9. The child is not a member of, nor entitled ot membership in, any Native American Tribe, therefore the child is not an "Indian Child" pursuant to the Indian Child Welfare Act. [if applicable]

10. Neither parent requires the services of a translator at the hearing and/or forms to be prepared in another language. [if applicable]

11. Petitioner(s) consents to accept custody of [name of adoptee] until such time as the child is adopted.

WHEREFORE, your petitioner prays your Honorable Court to enter an order directing that a time and place be set for a hearing on this Petition and upon holding said hearing to enter a Decree:

1. Finding that the involuntary termination of the parental rights of [name of natural parent] would best serve the needs and welfare of the child.

2. Directing the transfer of custody of [name of adoptee] to Petitioner(s).

3. Authorizing Petitioner(s) to give consent to the adoption of [name of adoptee] without further consent of, or notification to, [name of natural parent].

AND it will ever pray, etc.

Dated:_____________ By, ____________________________

[Name of Attorney], Esquire

Attorney for Petitioner

[Street Address]

[Telephone Number]

Attorney I.D. No.

STATE OF ______________________

COUNTY OF ____________________

Personally appeared before me, a notary public, [Name of Petitioners], known to me (or satisfactorily proven) to be the Petitioner(s) herein, who being duly sworn/affirmed according to law, deposes and says the facts set forth in the foregoing are true and correct according to the best of the Petitioner(s) information, knowledge and belief.

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

__________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(f)Confirmation of Consent. A petition for confirmation of consent under 23 Pa. C.S.A. § 2504(a) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

PETITION FOR CONFIRMATION OF CONSENT

23 Pa. C.S.A. § 2504(a)

To the Honorable, the Judges of said Court:

The petition of [name of petitioner], respectfully represents:

1. That your petitioner, [name of petitioner], [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania][relation to adoptee], [having its office at][residing at] [address], [county] County, Pennsylvania, has the care and custody of [name of adoptee], a minor [sex of adoptee] child born [date of birth] in [place of birth], [county of birth] County, Pennsylvania. The child was born to [name of natural mother], Mother, and [name of natural father], Father.

3. The mother of [name of adoptee] is [name of natural mother], her address being [street], [city], Pennsylvania, [zip code]; she is [age] years of age, having been born on [date of birth], in [place of birth]; her race is [racial background], she is currently [un]married, she was [not] married at the time of the birth of the child and during one year prior thereto, and her religious affiliation is [religion].

4. The natural father of [name of adoptee] is [name of natural father], whose current residence is [street], [city], Pennsylvania, [zip code]; he is [age] years of age, born on [date of birth], in [place of birth]; his race is [racial background], he is currently [un] married, he was [not] married at the time of the birth of the child and during one year prior thereto, and his religious affiliation is [religion].

5. [Name of consenting parent] has executed a consent for the subsequent adoption of [name of adoptee], said consent being attached hereto and incorporated herein as "Exhibit A."

6. The aforesaid consent of was executed on [date of execution] and more than thirty (30) days have elapsed since the dates without the said [name of consenting parent] filing or proceeding with a petition for the voluntary relinquishment of his/her parental rights.

7. [Name of petitioners] consents to accept custody of [name of adoptee].

8. The child is not a member of, nor entitled to membership in, any Native American Tribe, therefore the child is not an "Indian Child" pursuant to the Indian Child Welfare Act. [if applicable]

9. Neither parent requires the services of a translator at the hearing and/or forms to be prepared in another language. [if applicable]

10. [Name of consenting parent] is not entitled to the benefits of the Servicemembers Civil Relief Act of 2003 (50 U.S.C. App. 501 et seq.).

11. Your petitioners seek to confirm the consent to adoption executed by the aforesaid pursuant to Section 2504 of the Adoption Act of 1980, as amended (23 Pa. C.S.A., Section 2504) .

WHEREFORE, your petitioner prays your Honorable Court to make a decree confirming the consent to adoption executed by [name of consenting parent] with respect to the minor child born to [names of natural parents], on [date of birth of adoptee], in [place of birth], [county of birth] County, Pennsylvania, known as [name of adoptee], thereby terminating all his rights and duties as father/mother of said [name of adoptee] and awarding custody of [name of adoptee] to [petitioner], under the provision of Section 2521 of the Adoption Code, and permitting the adoption of [name of adoptee] to proceed without further notice to or consent from [name of consenting parent].

AND it will ever pray, etc.

Dated:_____________ By, ____________________________

[Name of Attorney], Esquire Attorney for Petitioner

[Street Address]

[Telephone Number]

Attorney I.D. No.

STATE OF ______________________

COUNTY OF ____________________

________________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

____________________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(g)Order Scheduling Hearing. The orders scheduling the hearing on the Petition for Involuntary Termination of Parental Rights, the Petition for Adoption, and the Petition for Confirmation of Consent shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

ORDER

23 Pa. C.S.A. § 2504(b)

AND NOW, this ___ day of __________, 20____, the within Petition for Involuntary Termination of Parental Rights/ Petition for Adoption/ Petition to Confirm Consent having been presented in Chambers, read, considered and ordered filed, ___________, the ___day of ____________, 20 ___, at ______o'clock ___m., prevailing time, in the assigned Court Room of the Franklin County Courthouse, Chambersburg, Franklin County, Pennsylvania, is fixed as the time and place of hearing thereon. Notice of the said hearing shall be given to [name of natural mother]; [name of attorney for natural mother], Esquire, Attorney for Natural Mother; [name of natural father]; [name of attorney for natural father], Esquire, Attorney for Natural Father; and [name of guardian ad litem], Esquire, Guardian Ad Litem for the above-referenced child.

By the Court,

_________________

(h)Notice of Confirmation Hearing: The notice of the hearing for Confirmation of Consent shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

NOTICE

23 Pa. C.S.A. § 2504(b) and 2513(b)

TO: [Name of Natural Parent],

A petition has been filed asking the court to put an end to all rights you have to your child, [name of adoptee]. The court has set a hearing to consider ending your rights to your child. That hearing will be held at Courtroom No. [Courtroom], the Franklin County Courthouse, 157 Lincoln Way East, Chambersburg, Pennsylvania, on [date of hearing] at [time of hearing]. Your presence is required at this hearing. If you do not appear at this hearing, the Court may decide that you are not interested in retaining your rights to your child, and your failure to appear may affect the Court's decision on whether to end your rights to your child. You are warned that even if you fail to appear at the scheduled hearing, the hearing will go on without you and the Court may end your rights to your child without you being present. You have a right to be represented at the hearing by a lawyer. You should take this paper to your lawyer at once. If you do not have a lawyer or cannot afford one, go to or telephone the office set forth below to find out where you can get legal help.

Franklin County Court Administrator

Franklin County Courthouse, 3^rd Floor

157 Lincoln Way East

Chambersburg, PA 17201

(717) 261-3848

The Court of Common Pleas of Franklin County is required by law to comply with the Americans With Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the Court, please contact the Office of the Court Administrator. All arrangements must be made at least 72 hours prior to a hearing or business before the Court. You must attend the scheduled hearing.

___________________

[Name of Attorney], Esquire

Attorney for Petitioner

(i)Notice of Involuntary Termination Hearing: The notice of the hearing for Involuntary Termination of Parental Rights shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

NOTICE

23 Pa. C.S.A. § 2513(b)

TO: [Name of Natural Parent]

A petition has been filed asking the Court to put an end to all rights you have to your child, [name of adoptee]. The Court has set a hearing to consider ending your rights to your child. The hearing will be held in the Franklin County Court House, Chambersburg, Franklin County, Pennsylvania, on [date of hearing] at [time of hearing]. If you do not appear at this hearing, the Court may decide that you are not interested in retaining your rights to your child, and your failure to appear may affect the Court's decision on whether to end your rights to your child. You are warned that even if you fail to appear at the scheduled hearing, the hearing will go on without you and the Court may end your rights to your child without you being present. You have a right to be represented at the hearing by a lawyer. You should take this paper to your lawyer at once. If you do not have a lawyer and desire to have one appointed, apply at the office set forth below and one shall be appointed for you.

Franklin County Court Administrator

Franklin County Courthouse, 3^rd Floor

157 Lincoln Way East

Chambersburg, PA 17201

(717) 261-3848

_____________________

[Name of Attorney], Esquire

Attorney for Petitioner

(j)Petition for Leave to Provide Notice by Publication: The Petition for Leave to Provide Notice by publication as per Pa. O.C. Rule 15.6 shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

PETITION FOR LEAVE TO PROVIDE NOTICE BY PUBLICATION

Pa. O.C. Rule 15.6

To the Honorable, the Judges of said Court:

The petition of [name of petitioner], respectfully represents:

1. That your petitioner, [name of petitioner], [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania][relation to adoptee], [having its office at][residing at] [address], Chambersburg, Franklin County, Pennsylvania, has the care and custody of [name of adoptee], a minor [sex of adoptee] child born [date of birth of adoptee], in Franklin County, Pennsylvania. The child was born to [name of natural mother], Mother, and [name of natural father], Father.

4. The natural father of [name of adoptee] is [name of natural father], whose current residence is [street], [city], Pennsylvania, [zip code]; he is [age] years of age, having been born on [date of birth], in [place of birth]; his race is [racial background], he is currently [un] married, he was [not] married at the time of the birth of the child and during one year prior thereto, and his religious affiliation is [religion].

5. Petitioner had made the following efforts to locate [name of natural parent]:

A) .

B) .

C) .

D) .

6. Despite the above mentioned diligent efforts to locate [name of natural parent], Petitioner[s] [has][have] been unable to ascertain their whereabouts.

WHEREFORE, your petitioner prays your Honorable Court to enter a decree granting leave to Petitioner[s] to provide notice to [name of natural parent] by Publication pursuant to Pennsylvania Rule of Orphan's Court 15.6(2).

AND it will ever pray, etc.

Date: _____________ _____________________________

[Name of Attorney], Esquire

Attorney for Petitioner

[Street Address]

[Telephone Number]

Attorney I.D. No.

STATE OF ______________________

COUNTY OF ____________________

_______________________________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

_____________________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(k)Order Authorizing Service by Publication: The Order authorizing service by publication as per Pa. O.C. Rule 15.6 shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

ORDER

Pa. O.C. Rule 15.6

AND NOW, this ___ day of __________, 20___, the within Petition for Leave to Provide Notice by Publication having been presented in Chambers, read, considered and ordered filed, and ___________, the ___ day of ____________, 20___, at ______o'clock ___m., prevailing time, in the assigned Court Room of the Franklin County Courthouse, 157 Lincoln Way East, Chambersburg, Franklin County, Pennsylvania, having been fixed as the time and place of hearing thereon, Petitioner[s] [is][are] hereby authorized to provide service to by publication in the [name of publication] Newspaper and [name of county] County Legal Journal, pursuant to Pennsylvania Rule of Orphan's Court 15.6(2).

By the Court,

___________________

(l)Decree Involuntarily Terminating Natural Parent's Rights: The decree terminating the parental rights of a natural parent shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

DECREE

23 Pa. C.S.A. § 2513(d) and Pa. O.C. Rule 15.4(d)

AND NOW, this _____th day of ___________, 20___, the above named matter having been heard in a private hearing on [date of hearing], at [time of hearing], and it appearing to the Court that the facts set forth in the petition are true and correct, and that service of the notice of the foregoing private hearing, together with a copy of the Petition for Involuntary Termination of Parental Rights has been made upon [name of natural mother], Natural Mother; [name of attorney for natural mother], Esquire, Attorney for the Natural Mother; [name of attorney for natural father], Esquire, Attorney for the Natural Father; [name of natural father], Natural Father; and [name of guardian ad litem], Esquire, Guardian Ad Litem for the Child, in the manner required by this Court, and as evidenced by an Affidavit of Service filed in this matter by [name of attorney for petitioner], Attorney for the petitioner, the Court makes the following findings of fact and conclusions of law:

FINDINGS OF FACT

1. That your petitioner, [name of petitioner], [an agency for the placement of children approved by the Department of Public Welfare of the Commonwealth of Pennsylvania], [having its office][residing at] at [address], [county of residence] County, Pennsylvania, has the care and custody pursuant to an Order of Court dated [date of order granting custody] of [name of adoptee], a minor [sex of adoptee] child born [date of birth] in [place of birth] County, Pennsylvania. [Child's name] was born to [mother] and [father].

2. That [child] is a [racial background] [sex of adoptee] child who is [age] years old, having been born on [date of birth] in [county of birth] County, Pennsylvania. Their religious affiliation is [religion].

3. That the mother of [name of adoptee] is [name of natural mother], her address being [street], [city], Pennsylvania, [zip code]; she is [age] years of age, having been born on [date of birth], in [place of birth], Pennsylvania; her race is [racial background], she is currently [un]married, she was [not] married at the time of the birth of the child and during one year prior thereto, and her religious affiliation is [religion].

4. That the natural father of [name of adoptee] is [name of natural father], whose current address is [street], [city], Pennsylvania, [zip code]; he is [age] years of age, having been born on [date of birth]; his race is [racial background], he is currently [un] married, he was [not] married at the time of the birth of the child and during one year prior thereto; and his religious affiliation is [religion].

5. The legal grounds for the involuntary termination of the parental rights of [name of natural parent] are as follows:

c)23 Pa. C.S. § 2511(a)(3)- The parent is the presumptive but not the natural father of the child.

g)23 Pa. C.S. § 2511(a)(7)- The parent is the father of a child who was conceived as a result of a rape or incest.

i) The parent has been convicted of one of the following in which the victim was a child of the parent:

1. An offense under 18 Pa. C.S. Ch. 25 (relating to criminal homicide);

2. A felony under 18 Pa. C.S.§ 2702 (relating to aggravated assault);

3. An offense on another jurisdiction equivalent to an offense in subparagraph (1) or (2); or

4. An attempt, solicitation or conspiracy to commit an offense in subparagraph (1), (2), or (3).

6. The facts which support said grounds for termination are as follows:

7. [Name of natural parent] is not entitled to the benefits of the Servicemembers Civil Relief Act of 2003. (50 U.S.C. App. 501 et seq.).

8. The child is/is not an "Indian Child" subject to the protections of the Indian Child Welfare Act.

9. [Agency name][parent's name] consents to accept custody of [name of adoptee] until such time as the child is adopted.

10. Notices required per Act 101 of 2010 (23 Pa. C.S. §§ 2731-2742) have been served on both parents and the child as evidenced by the Affidavit of Service filed in this matter.

CONCLUSIONS OF LAW

1. The Court has jurisdiction of the parties and the subject matter under 23 Pa.C.S.A. Sec 2501 et seq.

2. The prayer of the petition should be granted, all requirements of the applicable statute having been complied with.

3. The Court finds by clear and convincing evidence the existence of valid grounds to involuntarily terminate the parental rights of [name of natural parent] pursuant to the following statutory authority:

(a) [TPR sections set forth above]

NOW, THEREFORE, IT IS ORDERED AND DECREED THAT:

(1) The parental rights and duties of the [name of natural parent], Natural [Mother/Father] of [name of adoptee], are hereby terminated, and

(2) Custody of [name of adoptee] is awarded to [Agency][parent] under the provisions of Section 2521 of the Adoption Act, and

(3) [Mother Name] and [Father Name] [are/is] hereby advised pursuant to Act 101 of 2010 (23 Pa. C.S. §§ 2731-2742) that [she/he/they] [have/has] a continuing right as [a] parent(s) to voluntarily place on file and update social and medical history information, whether or not the medical condition is in existence or discoverable at the time of the present adoption. The information you choose to provide could be important to the child's present and future medical needs. Requests to release the information will be honored if certain conditions set forth by Act 101 are met. All information will be maintained and distributed in a manner that fully protects your privacy. [Mother Name] and [Father Name] [are/is] further advised that [she/he/they] may obtain the appropriate form to file social and medical history information, either now or in the future, by contacting the Pennsylvania Adoption Information Registry (PAIR), Franklin County Children and Youth Service, any private licensed adoption agency, Franklin County Clerk of Orphan's Court Office, or it may be found online.

(4) [Name of natural parent] is hereby advised that they have the right to appeal this Order of Court within thirty days of its entry. Notice of such appeal shall be provided in accordance with the Pennsylvania Rules of Appellate Procedure.

(5) The Clerk of Orphan's Court is hereby directed to provide this Order to the following by First Class Mail and to note date of mailing in the adoption file:

By the Court,

______________

(m)Decree Confirming Consent: The decree confirming a consent to adoption shall be substantially in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

DECREE

23 Pa. C.S.A. § 2504(b)

AND NOW, this _____th day of ___________, 20___, the above named matter having been heard in a private hearing on [date of hearing], at [time of hearing] o'clock [a/p].m. and it appearing to the Court that: the facts set forth in the petition are true and correct, and that notice of the foregoing private hearing, together with a copy of the petition for the Confirmation of Consent has been given to in the manner required by this Court; and [name(s) of petitioners], petitioner(s), has filed a petition and consented to accept custody of said child until such time as the child is adopted; and the prayer of the petition should be granted and all requirements of the applicable statutes have been complied with;

NOW, THEREFORE, IT IS ORDERED AND DECREED, that

1. The consent executed by [name of consenting parent] is hereby confirmed;

2. The parental rights and duties of [name of consenting parent] are hereby terminated;

3. Custody of [name of adoptee] is awarded to [petitioner], under the provisions of Section 2521 of the Adoption Act;

4. The adoption of [name of adoptee] may proceed without further notice to or consent from .

5. [Name of consenting parent] is not entitled to the benefits of the Servicemembers Civil Relief Act of 2003. (50 U.S.C. App. 501 et seq.).

6. The child is/is not an "Indian Child" subject to the protections of the Indian Child Welfare Act.

7. [Mother Name] and [Father Name] [are/is] hereby advised pursuant to Act 101 of 2010 (23 Pa. C.S. §§ 2731-2742) that [she/he/they] [have/has] a continuing right as [a] parent(s) to voluntarily place on file and update social and medical history information, whether or not the medical condition is in existence or discoverable at the time of the present adoption. The information you choose to provide could be important to the child's present and future medical needs. Requests to release the information will be honored if certain conditions set forth by Act 101 are met. All information will be maintained and distributed in a manner that fully protects your privacy. [Mother Name] and [Father Name] [are/is] further advised that [she/he/they] may obtain the appropriate form to file social and medical history information, either now or in the future, by contacting the Pennsylvania Adoption Information Registry (PAIR), Franklin County Children and Youth Service, any private licensed adoption agency, Franklin County Clerk of Orphan's Court Office, or it may be found online.

8. [Mother Name] and [Father Name] [are/is] hereby advised that [they/he/she] [have/has] the right to appeal this Order of Court within thirty days of its entry. Notice of such appeal shall be provided in accordance with the Pennsylvania Rules of Appellate Procedure.

9. This Order shall be mailed by the Clerk of Orphans' Court by first class mail with date of mailing being documented to the following:

By the Court,

_____________

(n)Report of Intention to Adopt: The report of intention to adopt described in 23 Pa. C.S.A. § 2531(b) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

REPORT OF INTENTION TO ADOPT

23 Pa. C.S.A. § 2531(b)

(To be filed by every person now having or hereafter receiving or retaining custody or physical care of any child, for the purpose or with the intention of adopting a child under the age of eighteen years within thirty days after the date of receipt of the custody or physical care of the child. No report shall be required when the child is the child, grandchild, stepchild, brother or sister of the whole or half blood, or niece or nephew by blood, marriage, or adoption, of the person receiving or retaining custody or physical care.)

Part A.

(To be completed by persons having or receiving a child from an Agency.)

1. The name and address of Agency is [name and address of Agency].

Part B.

(To be completed by persons having or receiving a child from an intermediary other than an Agency.)

1. Child is [name of adoptee], a [racial heritage] [male][female] child, who is [age] years of age, having been born [date of birth] in [place of birth], whose religious affiliation is [religion].

2. The name and address of intermediary is [name and address of intermediary].

Part C.

(To be completed by all persons required to file report.)

1. The circumstances surrounding the placement or receipt of physical care of the child are as follows:

A) Date of completion of Pre-placement Investigation (Copy attached hereto):

B) Date when [I][we] first applied to the agency was:

C) The reason this particular child was placed with [me][us] is:

D) The length of time [I][we] have known the child or about the child is:

E) [I][We] [do][do not] know the natural parents or their families.

F) The date the child was placed in [my][our] home is:

A) There [was][was not] any fee or expenses paid or to be paid to the Intermediary or other persons.

B) If there was fees paid or to be paid above, the following is an itemized accounting of the moneys or other consideration paid or to be paid, and to whom:

$ to for .

to for .

A) To the best of [my][our] knowledge and beliefs, the natural parents whose parental rights were terminated [have][have not] received counseling.

B) If counseling has been received, it was received on [date] by [counselor] whose address is [address of office].

[I] [We] acknowledge that we have been advised or know that the natural parent(s) may revoke their consent to the adoption within thirty days of the date of execution of the consent.

Signed this _____day of ___________, 20_____.

__________________ _________________

Petitioner Petitioner

(o)Report of Intermediary: The report of intermediary required under 23 Pa. C.S.A. § 2533(b) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

REPORT OF INTERMEDIARY

23 Pa. C.S.A. § 2533(b)

(To be filed by Intermediary who or which arranged the adoption placement of any child under the age of eighteen years within six months after filing a Report of Intention to Adopt.)

1. The name and address of Intermediary is [name and address of intermediary].

2. Adoptee is [name of adoptee], a [racial heritage] [male][female] child who is [age] years of age, having been born on [date of birth] in [place of birth], whose religious affiliation is [religion].

3. Adoptee was placed with adopting parents on [date of placement].

4. The Natural Mother of Adoptee is [name of natural mother], a [racial heritage] female, who is [age] years of age, having been born on [date of birth] in [place of birth], she was [married] [unmarried] at the time of adoptee's birth, and was [married][unmarried] within one year prior to adoptee's date of birth, and whose religious affiliation is [religion].

5. The Natural Father of Adoptee is [name of natural father], a [racial heritage] male, who is [age] years of age, having been born on [date of birth] in [place of birth], he was [married] [unmarried] at the time of adoptee's birth, and was [married][unmarried] within one year prior to adoptee's date of birth, and whose religious affiliation is [religion].

6. Parental rights were terminated by [identify court] by decree dated [date of termination decree], docketed to [docket number] and custody was awarded to [name of adopting parents/Agency].

A) To the best of [my][our] knowledge and beliefs, the natural parents whose parental rights were terminated [have][have not] received counseling.

B) If counseling has been received, it was received on [date] by [counselor] whose address is [office address].

C) If no decree of termination and/or relinquishment was entered, the residence and mailing addresses of the natural parent(s) [is][are]:

Mother:

Father:

A) The exhibits required by Section 2534 of the Adoption Act are attached.

B) Consents required by Section 2711 of the Adoption Act are attached as exhibits.

C) Consents are not required under Sections 2713, 2714, and 2711 of the Adoption Act because:

9. [No][The following] moneys or consideration has been or will be paid or received by the Intermediary or to or by any other person or persons to the knowledge of the Intermediary by reason of the adoption placement.

$ to for .

10. The child owns or possesses the following described and valued property:

11. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of the Adoptee.

12. [If applicable] A birth certificate or registration of birth cannot be obtained for the following reasons:

13. Written notice of the filing of this Report and the date of the same will be given to the adopting parent(s) forthwith.

14. Medical information as defined in Section 2102 of the Adoption Act was obtained, and if not obtained the reason therefore is:

Signed this_____day of ___________, 20 _____.

____________________________________

Signature of Intermediary or Authorized Officer

STATE OF ______________________

COUNTY OF ____________________

_______________________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

______________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(p)Petition for Adoption: The petition for adoption in 23 Pa. C.S.A. § 2701 and Pa.O.C. Rule 15.5 shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

PETITION FOR ADOPTION

23 Pa. C.S.A. § 2701 and Pa. O.C. Rule 15.5

TO THE HONORABLE, THE JUDGES OF SAID COURT:

The petition of ____________________respectfully represents:

Your petitioner(s) (is) (are):

A. [Name of petitioner] residing at [residence and mailing address] who is (married) (single) and [age] years of age, having been born on [date of birth] and whose occupation is [occupation] religious affiliation is [religion], racial background is [racial heritage] and relationship to the proposed adoptee is [nature of relationship];

B. [Name of petitioner] residing at [residence and mailing address] who is (married) (single) and [age] years of age, having been born on [date of birth] and whose occupation is [occupation] religious affiliation is [religion], racial background is [racial heritage] and relationship to the proposed adoptee is [nature of relationship];

II.

A. The report of Intention to Adopt under Section 2533(has) (has not) been filed.

B. The report of the intermediary under Section 2533(has) (has not) been filed; however, in lieu thereof, Exhibit A is attached hereto.

III.

The name and address of the intermediary is:

IV.

Your petitioner(s) desire(s) to adopt [name of adoptee] who was born on [date of birth] and who has resided with your petitioner(s) since [date of placement] as one of (her)(his)(their) heirs and declare(s) that (she)(he)(they) will perform all of the duties of parent(s) to said adoptee.

A. Exhibits required by Section 2702 of the Adoption Act are attached.

B. Consents required by Section 2711 of the Adoption Act are attached as exhibits.

C. Consents are not required under Sections 2713, 2714 and 2711 of the Adoption Act by reason of (state facts):

D. Notices required by Act 101 of 2010 (23 Pa. C.S. § 2731-2742) have been provided to the birth parents, the adoptive parents, and the child, and are attached as Exhibit [exhibit number].

E. Exhibit containing vital statistics is attached as Exhibit [exhibit number].

VI.

(Strike out if not applicable) A birth certificate or certificate of registration of birth cannot be obtained for the adoptee and the petitioner would request that the Court establish a time and place of birth for said adoptee at the adoption hearing on the basis of the evidence presented. (Set forth reasons for failure to obtain a birth certificate or certificate of registration of birth and the efforts made to so obtain those documents):

VII.

That your petitioner(s) believing that the welfare of said adoptee will be promoted by said adoption, desire(s) that the relationship of parent and child be established between [names of petitioners] and the adoptee, and the adoptee shall be known as [new full name of child]; and (she)(he)(they) respectfully pray(s) that the Court make a decree in accordance with this prayer.

_______________

- Petitioner

_______________

- Petitioner

STATE OF ______________________

COUNTY OF ____________________

_________________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

____________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(q)Exhibit "A": Exhibit "A" of the adoption petition in (p) above shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

EXHIBIT A

1. Name and Address of Intermediary:

2. Adoptee, [name of adoptee], is [age] years of age, having been born on [date of birth], in [place of birth], Pennsylvania, whose racial background is [racial heritage], and religious affiliation is [religion].

3. Adoptee was placed with adopting parent(s) on [date of placement].

4. The natural parent(s) of adoptee is/are:

a. Mother: [name], is [age] years of age, having been born on [date of birth], in [place of birth], Pennsylvania; their racial background is [racial heritage]; they were [married][single] at the time of the adoptee's birth and were [married][single] within one year prior to the birth of Adoptee; and their religious affiliation is [religion].

b. Father: [name], is [age] years of age, having been born on [date of birth], in [place of birth], Pennsylvania; their racial background is [racial heritage]; they were [married] [single] at the time of the Adoptee's birth and were [married][single] within one year prior to the birth of the Adoptee; and their religious affiliation is [religion].

A. Parental rights and duties were terminated and/or relinquished by [Court where terminated] by decree dated [date of termination decree], docketed to [docket number], and custody was awarded to [name of petitioners/Agency].

B. If no decree of termination or relinquishment has been entered, the residence and mailing addresses of the natural parents(s) [is][are]:

1) Mother:

2) Father:

A. Exhibits required by Section 2543 of the Adoption Act are attached.

B. Consents required by Section 2711 of the Adoption Act are attached as exhibits.

C. Consents are not required under Sections 2713, 2714, and 2711 of the Adoption Act for the following reasons:

7. [No][The following] moneys or consideration have been or will be paid or received by the intermediary or to or by any other person or persons to the knowledge of the intermediary by reason of the adoption placement.

8. State value and describe all property owned or possessed by Adoptee:

9. No provisions of any act regulating interstate placement of children have been violated with respect to the placement of the Adoptee.

10. [Strike if not applicable] A birth certificate or registration of birth cannot be obtained for the following reasons:

11. Written notice of the filing of this report and the date of the same will be given to the adopting parent(s) forthwith.

12. Medical history information as defined in Section 2102 of the Adoption Act was obtained, and if not obtained, the reason therefore is as follows:

Signed this _____day of ___________, 20 _____.

_____________________ ______________________

Petitioner Petitioner

STATE OF ______________________

COUNTY OF ____________________

_______________________ __________________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

_______________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(r) Vital Statistics Exhibit: The vital statistics exhibit of the adoption petition in (p) above shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

ADOPTION VITAL STATISTICS EXHIBIT

1. Adoptee, [name of adoptee] is a [male][female], who is [age] years of age, having been born on [date of birth], in [place of birth], [county of birth] County, [state], United States.

2. The new name proposed for Adoptee is [new name of adoptee].

3. The Adoptive Father's full name is [name of adopting father]; he is [racial heritage]; his age at the time of birth of Adoptee was [age], having been born on [date of birth], in [place of birth]; and his usual occupation is [occupation], the industry or business being [nature of employment].

4. The Adoptive Mother's full maiden name is [maiden name of adopting mother]; she is [racial heritage]; her age at the time of birth of Adoptee was [age], having been born on [date of birth], in [place of birth]; and her usual occupation is [occupation], he industry or business being [nature of employment].

5. The Adoptive Parents mailing address at the time of the adoption is [address].

6. The attorney handling the adoption is [name of adopting parents attorney], Esquire, whose mailing address is [address].

(s)Disclosure of Fees: The disclosure of fees statement as required in 23 Pa. C.S.A. §§ 2533(b)(8) and 2724(a) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

: ______-ADOPT-__________

Born

DISCLOSURE OF FEES AND COSTS

23 Pa. C.S.A. §§ 2533(b)(8) and 2724(a)

$ Clerk of Courts, Filing fees

Notary Fees

Attorney Fees

Vital Statistics, birth certificate

Home Study

Agency Fees

Doctor Fees (Mother)

Doctor Fees (Baby)

Hospital Fees (Mother)

Hospital Fees (Baby)

Prescription Medications

Other-

_________

$ Total

[I] [We] certify that the above itemization of fees and costs paid by [name of petitioners], in connection with the above captioned adoption is accurate and complete to the best of my knowledge, information and belief. Signed this _____day of ___________, 20 _____.

_____________ _______________

Petitioner Petitioner

(t)Adoption Decree: The adoption decree as required in 23 Pa. C.S.A. § 2902 shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

DECREE

23 Pa. C.S.A. § 2902

AND NOW, this _____day of ___________, 20 _____, it appearing that the statements set forth in the Petition for Adoption filed and docketed in this matter are true, and that the welfare of the person proposed to be adopted will be promoted by such adoption, and that all requirements of the adoption law of Pennsylvania have been complied with,

IT IS HEREBY ORDERED AND DECREED that the adoption is granted and that the person proposed to be adopted by the petitioners, [name of petitioner] and [name of petitioner], shall have all the rights of a child and heir of said petitioners, and shall be subject to the duties of such child, and henceforth shall be known as [new name of adoptee].

BY THE COURT,

__________________

COMMONWEALTH OF PENNA . :

: ss.

COUNTY OF (FRANKLIN)(FULTON) :

I, _________________________, Clerk of Orphans' Court Division of the Court of Common Pleas of the 39 th Judicial District, Pennsylvania, (Franklin)(Fulton) County Branch, do hereby certify that the foregoing is a full, true and correct copy of a Decree of Adoption by the petitioners therein named as the same remains on file and of record in this office.

IN TESTIMONY WHEREOF, I have hereunto set

My hand and affixed the seal of ___________________

The said office this ________day of _______________, 200__.

Clerk, Orphans' Court Division,

Court of Common Pleas of the 39th Judicial District,

Pennsylvania, (Franklin)(Fulton) County Branch

(u)Acceptance of Service: The acceptance of service as described in 23 Pa. C.S.A. §§ 2503(a), 2513(b), 2721; Pa. O.C. Rule 15.6; Pa. R.C.P. 402(b) shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

ACCEPTANCE OF SERVICE

23 Pa. C.S.A. §§ 2503(a), 2513(b), 2721; Pa. O.C. Rule 15.6; Pa. R.C.P. 402(b)

I, [name of attorney], Esquire, counsel for [client name and relationship to adoptee], certify that I am authorized to accept service on behalf of and hereby accept service of the Petition to Involuntarily Terminate Parental Rights/Petition for Confirmation of Consent/Petition for Termination of Parental Rights/ Adoption Petition and the Order scheduling a hearing in the above-captioned matter.

____________________

Date

(v)Affidavit of Service: The affidavit of service shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

AFFIDAVIT OF SERVICE

STATE OF PENNSYLVANIA :

: ss.

COUNTY OF FRANKLIN :

[Name of attorney], Esquire, being duly sworn according to law, deposes and says that he/she served copies of the attached Notice of Hearing, copies of the petitions filed in this matter, and Order scheduling hearing on the following:

(1) [Name of attorney], Esquire, Guardian ad Litem for the child(ren), at [address] on [date] by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned;

(2) [Name of attorney], Esquire, Attorney for Natural Mother, [name of natural mother], at [address]on [date] as evidenced by an Acceptance of Service;

(3) [Name of natural mother], Natural Mother, at [address] on [date] by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned; and

(4) [Name of natural father], Natural Father, at [address] on [date] by First Class Mail, as evidenced by the Return Receipt attached and made a part hereof, and said article has not been returned.

The Notice required by Act 101 of 2010 was also served on [Mother]. [Father], [Child].

______________________

[Name of attorney], Esquire- Attorney for Petitioner

STATE OF ______________________

COUNTY OF ____________________

Personally appeared before me, a notary public, [Name of Attorney], known to me (or satisfactorily proven) to be the Petitioner herein, who being duly sworn/affirmed according to law, deposes and says the facts set forth in the foregoing are true and correct according to the best of the Petitioner's information, knowledge and belief.

_______________________

Sworn/affirmed and subscribed before me this ______day of ______________, 20__, before me, __________________, the undersigned officer.

In witness whereof, I hereunto set my hand and official seal.

________________________

(signature of notary public)

[Seal]

Title: __________________________

My commission expires: ___________

I maintain my office in: ____________

(w)Act 101 of 2010 Notice: The Notice required under Act 101 of 2010 shall be in substantially the following form:

IN THE COURT OF COMMON PLEAS OF THE 39T H JUDICIAL DISTRICT OF PENNSYLVANIA - FRANKLIN COUNTY BRANCH

IN RE: ADOPTION OF

: Orphans' Court Division

Born

: ______-ADOPT-__________

NOTICE REQUIRED BY ACT 101 OF 201023 Pa. C.S. §§ 2731 - 2742

Date:

To:

This is to inform you of an important option that may be available to you under Pennsylvania law. Act 101 of 2010 allows for an enforceable voluntary agreement for continuing contact or communication following an adoption between an adoptive parent, a child, a birth parent, and/or a birth relative of the child, if all parties agree and the voluntary agreement is approved by the court. The agreement must be signed and approved by the court to be legally binding.

A birth relative is defined only as a parent, grandparent, stepparent, sibling, uncle or aunt of the child's birth family, whether the relationship is by blood, marriage, or adoption.

This voluntary agreement may allow you to have continuing contact or communication, including, but not limited to:

Letters and/or e-mails; Photos and/or videos; Telephone calls and/or text messages; or Supervised or unsupervised visits.

If you are interested in learning more about this option for a voluntary agreement, you may contact an attorney of your choice.

Sincerely,

[Name of attorney], Esquire

Counsel for [name of client]

Frank. Cnty. Pa. 39-16