If you are adopting more than one child, fill out an adoption
request for each child.
Your name(s) (adopting parent(s)):
a.
b.
Relationship to child:
Street address:
City:
State:
Zip:
Telephone number:
Type of adoption (check one):
Judicial Council of California, www.courts.ca.gov
Revised January 1, 2018, Mandatory Form
Family Code, §§ 170–180, 7822, 7892.5, 8601.5, 8604, 8606, 8700,
8714, 8714.5, 8802, 8900–8905, 8908–8912, 8919, 8924, 8925,
9000, 9000.5, 9001, 9002, 9208;
Welfare and Institutions Code, §§ 366.24, 16119;
Cal. Rules of Court, rules 5.480–5.487, 5.730
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same time as this Adoption Request.
Agency (name):
Intercountry (name of agency):
Joinder will be filed.
Independent
Tribal customary adoption
(attach tribal customary adoption order)
Joinder is being filed at
Relative
Nonrelative
Relative
Nonrelative Additional Parent(s)
I/We filed this Adoption Request in this court because it is in the county
(check all that apply):
2
3
Adoption Request
ADOPT-200
Lawyer (if any): (Name, address, telephone numbers, e-mail address,
and State Bar number):
Where the adopting parent(s) live;
Where the child was born or where the child now lives;
Where an office of the agency that placed the child for adoption is located;
Where an office of the department or public adoption agency that is investigating the petition is located;
Where a placing birth parent or parents lived when the adoptive placement agreement, consent, or
relinquishment was signed;
Where a placing birth parent or parents live(s) when the petition was filed;
Where the child was freed for adoption.
This adoption may be subject to the Hague Adoption Convention (form ADOPT-216 must be filed with
this request).
ADOPT-200, Page 1 of 5
Adoption Request
(If the child is a dependent of the court, the Adoption Request must be filed in the county where the child was freed
for adoption or the county where the adopting parent(s) reside(s). See Fam. Code, § 8714.)
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
(To be completed by the clerk of the superior court
if a hearing date is available.)
Hearing is set for:
Date:
Dept.:
Room:
To the person served with this request: If you do
not come to this hearing, the judge can order the
adoption without your input.
Hearing
Date
Time:
Name and address of court if different from above:
I/We have received information about the Adoption Assistance Program, the Regional Center, mental health
services available through Medi-Cal or other programs, and federal and state tax credits that might be available.
If this is an agency adoption:
Child may have Indian ancestry:
Names of birth parents, if known:
Mother:
Father:
Whether you answered “Yes” or “No,” you must fill out and attach Indian Child Inquiry Attachment (form
ICWA-010(A)) and Parental Notification of Indian Status (form ICWA-020) or other proof that ICWA inquiry
has been completed in accordance with rule 5.481(a).
If you answered “Yes,” you must also fill out and attach Adoption of Indian Child (form ADOPT-220) if, after
notice, it is determined that ICWA does apply to the child.
Yes No
a.
b.
a.
b.
a.
All persons with parental rights agree that the child should be placed for adoption by the California Department
of Social Services or a county adoption agency or a licensed adoption agency (Fam. Code, § 8700) and have
signed a relinquishment form approved by the California Department of Social Services, and the time to revoke
the relinquishment has expired or been waived.
(If no, list the name and relationship to child of each person who has not signed the
relinquishment form or whose time to revoke the relinquishment has not expired or been waived):
b.
Yes No
Yes No
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10
9
7
5
6
Your name:
Case Number:
ADOPT-200,
Page 2 of 5
Adoption Request
Is the child a dependent of the court?
(If yes, fill out below):
Juvenile case number:
County:
Does the child have a legal guardian?
(If yes, attach a copy of the Letters of Guardianship and fill out below):
Date guardianship ordered:
County:
Case number:
Yes
No
a.
b.
c.
Yes
No
Child’s name before adoption (Fill out ONLY if this is an independent, stepparent, or tribal customary adoption):
Information about the child
b.
Date of birth:
Age:
Child’s address (if different from yours):
Street:
State: Zip:City:
The child’s new name will be:
c.
d.
a.
Boy
Girl
Place of birth (if known):
City:
Country:
State:
If the child is 12 or older, does the child agree to
the adoption?
e.
g.
f.
Date child was placed in your physical care:
Yes
No
Stepparent adoption to confirm parentage. (Select this option if you were married to or in a state-registered
domestic partnership with the birth parent at the time the child was born and you remain in that union.)
Stepparent
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Revised January 1, 2018
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agree to this adoption and will maintain their existing parental rights.
parental rights, signed by both the existing parent(s) and the adopting parent(s) is attached.
If this is a stepparent adoption:
The birth parent (name):
The adopting parents were married on or The domestic partnership was registered on
. (For court use only. This does not affect social worker’s recommendation.
There is no waiting period.)
Contact After Adoption Agreement (form ADOPT-310
)
(date):
Contact after adoption
All persons with existing parental rights
The birth parent (name):
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Case Number:
Your name:
b.
c.
d.
a.
has signed a consent will sign a consent.
has signed a consent will sign a consent.
The child was conceived by assisted reproduction in compliance with Family Code section 7613.
is attached will not be used
will be filed at least 30 days before the adoption hearing
This is a tribal customary adoption. Postadoption contact is governed by the attached tribal customary adoption
order.
is undecided at this time.
ADOPT-200, Page 3 of 5
Adoption Request
Revised January 1, 2018
11
This is an adoption conducted under the requirements of the Hague Adoption Convention and the child will be
moving or has already moved with the adopting parent(s) to another Hague Convention member country at the
conclusion of this adoption. If yes, child will be moving or has moved to (name of country):
and adopting parent(s)
c.
d.
seek(s) a California adoption
will be petitioning for a Hague Adoption Certificate
This is a tribal customary adoption under Welfare and Institutions Code section 366.24. Parental rights have
been modified under and in accordance with the attached tribal customary adoption order, and the child has been
ordered placed for adoption.
will be seeking a Hague Custody Declaration.
Yes
No
Yes
No
is not necessary because
(check the applicable reasons under Fam. Code, § 8606):
Consent for adoption is not necessary because (complete all sections that apply to your adoption):
a.
(1)
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The consent of the birth parent presumed father
The parent has been judicially deprived of the custody and control of the child.
I am seeking a stepparent adoption to confirm my parentage. At the time the child was born, I was married to
or in a state-registered domestic partnership with the parent who gave birth and we remain in that union.
form ADOPT-205 or declaration describing the circumstances of the child’s conception.
All persons with parental rights agree to the adoption and have signed the Independent Adoptive Placement
Agreement or consent on the appropriate California Department of Social Services form.
(If no, list the name and relationship to child of each person who has not signed the agreement form):
I/We will file promptly with the department or delegated county adoption agency the information required by
the department in the investigation of the proposed adoption.
d.
Yes
No
b.
c.
If this is an independent adoption:
A copy of the Independent Adoptive Placement Agreement from the California Department of Social Services is
attached. (This is required in most independent adoptions; see Fam. Code, § 8802.)
Yes
No
a.
This is an independent adoption involving additional parent(s):
Yes
No
An agreement waiving termination of
See attached
Completing the investigation or written report (Choose one)
e.
I will choose someone to do an investigation or written report. I understand that the person I choose must be
a licensed clinical social worker, a licensed marriage and family therapist, or work for a licensed private
adoption agency. I will pay this person or agency directly.
I would like the court to choose someone to do an investigation. I understand that the court can charge me
money for this investigation.
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d.
e.
I/We will ask the court to end the parental rights of (attach copy of Petition to Terminate Parental Rights or
Application for Freedom From Parental Custody, if filed):
Relationship to child:Name:
Relationship to child:Name:
Adopting parent has custody of the child by court order or by agreement with the other parent, and each of
the following persons with parental rights has not contacted the child and has not paid for the child’s care,
support, and education for one year or more when able to do so. (Fam. Code, § 8604(b).)
Relationship to child:Name:
Relationship to child:Name:
Relationship to child:Name:
b.
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
(Enter the date of the court order ending parental rights and attach a copy of the order.)
c.
(Attach a copy of the order.)
A court ended the parental rights of:
The child is the subject of a tribal customary adoption order under Welfare and Institutions Code section
366.24, which has modified the parental rights of:
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
(1)
(2)
The child has been left by the child’s parent or parents with no way to identify the child.
The child has been left in the custody of another person by both parents or the sole parent for six
months without providing for the child’s support, or without communication from the parent or
parents, with the intent to abandon the child.
(3)
One parent has left the child in the care and custody of the other parent for one year or longer
without providing for the child’s support or without communication from the parent, with the intent
to abandon the child.
f.
The child has been abandoned as follows:
(If any of the above boxes are checked, adopting parent must also check item 15(d) and file an Application
for Freedom From Parental Custody. See Fam. Code, § 7822(a).)
g.
The consent of the presumed father is not required because he did not become a presumed father before the
mother’s relinquishment or consent became irrevocable or the mother’s parental rights were terminated.
(Fam. Code, § 8604(a).)
The parent has relinquished the child under Family Code section 8700.
(3)
(4)
(5)
The parent has deserted the child without providing information to identify the child.
The parent has relinquished the child for adoption to a licensed or authorized child-placing agency in
another jurisdiction.
(2)
The parent has voluntarily surrendered the right to custody and control of the child in a judicial
proceeding in another jurisdiction, under a law of that jurisdiction providing for the surrender.
a.
Your name:
Case Number:
ADOPT-200,
Page 4 of 5
Adoption Request
Revised January 1, 2018
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Case Number:
Your name:
ADOPT-200, Page 5 of 5
Adoption Request
Revised January 1, 2018
17
for the following reason (Fam. Code, § 8601.5):
(Enter a date no earlier than the date parental rights were ended.)
I/We ask the court to approve the adoption and to declare that the adopting parents and the child have the legal
relationship of parent and child, with all the rights and duties of this relationship, including the right of
inheritance.
I/We ask the court to date its order approving the adoption as of an earlier date
(date):
This is a tribal customary adoption. I/We ask the court to approve the adoption and to declare that the adopting
parents and the child have the legal relationship of parent and child, with all of the rights and duties stated in the
attached tribal customary adoption order and in accordance with Welfare and Institutions Code section 366.24.
Suitability for adoption
Each adopting parent:
Will support and care for the child;
Has a suitable home for the child; and
Agrees to adopt the child.
Is at least 10 years older than the child or
meets the criteria in Family Code section
8601(b);
Will treat the child as his or her own;
a.
b.
c.
d.
e.
If a lawyer is representing you in this case, he or she must sign here:
Date:
Signature of lawyer for adopting parent(s)
I declare under penalty of perjury under the laws of the State of California that the information in this form and all
its attachments is true and correct to my knowledge. This means that if I lie on this form, I am guilty of a crime.
Signature of adopting parent
Type or print lawyer’s name
Date:
Type or print your name
Signature of adopting parent
Date:
Type or print your name
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NOTICE—ACCESS TO AFFORDABLE HEALTH INSURANCE: Do you or someone in your household need affordable health
insurance? If so, you should apply for Covered California. Covered California can help reduce the cost you pay toward high-quality
affordable health care. For more information, visit www.coveredca.com. Or call Covered California at 1-800-300-1506 (English) or
1-800-300-0213 (Spanish).
h.
Each of the following persons with parental rights has died:
Relationship to child:Name:
Relationship to child:Name:
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