Fillable 47 Petition To Confirm Consent To Adoption.html (County of York)

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47 Petition To Confirm Consent To Adoption.html (County of York)

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IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA,
ORPHANS’ COURT DIVISION
IN RE: Adoption of
:
:
:
:
No.
(Adoptee’s name exactly as it appears on birth certificate)
PETITION TO CONFIRM CONSENT TO ADOPTION
23 Pa.C.S. §2504
TO THE HONORABLE, THE JUDGE OF SAID COURT:
The following is respectfully represented:
a) Name:
b) Address:
2. If petitioner is an intermediary, state complete name and address:
b) Address:
3. This petition is filed with respect to:
a. Name :
(Exactly as it appears on birth certificate)
b. Date of birth:
c. Place of birth:
d. Age:
Sex:
4. Biological mother information:
a. Name :
(Exactly as it appears on birth certificate)
b. Present address:
c. If unknown, list last known address:
d. Date of birth:
Age:
a) Name:
Form A 2504
1
Revised 05/ 2018
5. Legal father information:
a. Name :
(Exactly as it appears on birth certificate)
b. Present address:
c. If unknown, list last known address:
d. Date of birth:
Age:
e. Is he also the biological father?
6. Putative father information:
a. Name :
(Exactly as it appears on birth certificate)
b. Present address:
c. If unknown, list last known address:
d. Date of birth:
Age:
e. Circumstances indicating the putative father’s status:
7. Such parent, parents or putative father has/have executed consent or consents to this adoption.
The original(s) is/are attached to this petition.
8. Any Putative father:
a.
executed a consent to the adoption; and, (Choose one: Has / has not)
b.
filed an acknowledgment of paternity or claim of paternity pursuant to 23 Pa.C.
S. §5103. (Choose one: Has / has not)
2
Individual Petitioner
Individual Petitioner
Intermediary
Attorney for Petitioner(s)
By
Authorized Signature
VERIFICATION
This _____day of ______________________, 20____, the foregoing Petitioner(s) hereby verify,
subject to the penalties of 18 Pa.C.S. §4904 (relating to unsown falsification to authorities), that the
facts set forth in the foregoing petition which are within their knowledge are true, and as to the facts
based on information received, after diligent inquiry, petitioner(s) believe them to be true.
Individual Petitioner
Individual Petitioner
Intermediary
By
Authorized Signature
3
WHEREFORE, the petitioner(s) pray the Court to hold a hearing for the purpose of confirming the
intention of the parent, parents, or putative father to voluntarily relinquish their rights and duties as
evidenced by the consents to the adoption and to enter a decree terminating their parental rights
duties as provided in 23 Pa.C.S. §2504.
ORDER OF COURT
AND NOW, TO WIT, THIS ____ day of _________________, 20____, the foregoing petition is ordered filed,
and a private hearing thereon is fixed for
at _____ _______ , in Room No. in the York County Judicial Center, York, PA. At least ten (10) days’
notice of the hearing in the form prescribed by 23 Pa.C.S. §2513 (b) shall be given by personal service or
by registered or certified mail, at the present or last known address, to the parent, parents or putative
father listed in the petition, and to the parent or guardian of any who have not reached 18 years of age.
Notice shall state the parental rights of the parent, parents or putative father may be terminated as a
result of the hearing.
, Esquire, is hereby appointed to represent the child listed
in paragraph 3 of the petition.
BY THE COURT:
Judge
4
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Completed 6 August 2020

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