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IN THE COURT OF COMMON PLEAS OF YORK (County of York)

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BROWSE COUNTY OF YORK (PA) FORMS

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Revised 05/2018 1
IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA
ORPHANS’ COURT DIVISION
In Re: :
:
Adoption of : No._____________________
_____________________________________ :
(Adoptee’s name as on birth certificate) :
REPORT OF INTENTION TO ADOPT PURSUANT TO 23 Pa.C.S. §2531
The following is respectfully reported to the Court:
1. The name(s) and address(es) of the undersigned are:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. The date and circumstances surrounding the retention of custody or physical care of the child under
eighteen (18) years of age are:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. A pre-placement investigation, if conducted was concluded on ______________________________.
A copy of the pre-placement report, prepared pursuant to 23 Pa.C.S.
§2530 is attached.
4. The following is pertinent information with respect to such child:
a. Name: _____________________________________________________
b. Date of Birth: _______________________________________________
c. Place of Birth: _______________________________________________
d. Age: _______________________________________________________
e. Sex: ________________________________________________________
f. Racial background: ____________________________________________
g. Religious affiliation (if any): _____________________________________
5. The name and address of the intermediary:
_____________________________________________________________________________________
2
6. A Complete itemization of all moneys and consideration paid or to be paid to the intermediary is as
follows:
$_____________________ __________________________________________________________
$_____________________ __________________________________________________________
$_____________________ __________________________________________________________
7. The natural parent(s)
__________Has/have received counseling with respect to the termination of parental rights and
the alternative thereto. The following is the name and address of the agency or counselor who provided
the counseling and the dates on which the counseling occurred:
a. Name and address of agency or counselor:
___________________________________________________________________________
b. Date(s) of counseling: ________________________________________________________
__________Has/have not received counseling with respect to the termination of parental rights
and the alternatives thereto.
Respectfully submitted this ________day of _________________________________, 20______.
I acknowledge that I have been advised or know and understand that the BIRTH father or putative
father may revoke the consent to the adoption of this child within thirty (30) days after the later of the
birth of the child or the date he has executed the consent to an adoption and that the BIRTH mother
may revoke the consent to an adoption of this child within thirty (30) days after the date she has
executed the consent.
__________________________________________ _______________________________________
Attorney for Petitioner(s) ,Petitioner
Name:____________________________________ _______________________________________
Address:__________________________________ ,Petitioner
Phone No.:________________________________
Supreme Court ID No.:______________________
3
IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA
ORPHANS’ COURT DIVISION
In Re: :
: No. _______________________
Adoption of :
______________________________________ :
(Adoptee’s Name as on Birth Certificate) :
ORDER
AND NOW, TO WIT, this _________ day of ____________________, 20___,
the foregoing Report of Intention to Adopt is ordered filed and
________________________________________________is hereby appointed to
make an investigation and report covering all pertinent information regarding the
suitability of the placement as required by 23 Pa.C.S. §2535. Any costs of such
investigation shall be paid by the proposed adopters.
By the Court:
_______________________________________
Judge
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IN THE COURT OF COMMON PLEAS OF YORK (County of York)

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Completed 6 August 2020

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