700-00131A – Petition to Adopt Adult (11/2018) Page 2 of 4
Prospective Adoptive Parent B Information:
Full Name Prospective Adoptive Parent B: _______________________________________________________
Date of Birth: _____________________________ Place of Birth: _____________________________
Maiden Name: _______________________________________________________________________
Complete Mailing Address: _________________________________________________________________
Town & State of Residence: ______________________________________________________________
Length of Residence at Current Address: ______________ Phone Number: ____________________________
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, state the date and place of marriage: _____________________________________________
State the Duration and Nature of the relationship between the Adoptee and Adoptive Parents:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Part II - Certifications by Petitioners
The prospective adoptive parent(s) and the adoptee certify as follows:
1. The prospective adoptive parent(s) and the adoptee desire to assume the legal relationship of parent
and child and to have all of the rights and be subject to all of the duties of that relationship.
2. The adoptee understands that a consequence of the adoption will be to terminate the adoptee's
relationship as the child of an existing parent, but if the adoptive parent is the adoptee's stepparent, the
adoption will not affect the adoptee's relationship with a parent who is the stepparent's spouse, but will
terminate the adoptee's relationship to the adoptee's other parent, except for the right to inherit
from or through that parent.
3. The adoptee and the prospective parent(s) understand the consequences the adoption may have for
any right of inheritance, property, or support from adoptive and biological parents.
Part III - Persons Interested in Adoption Proceeding
Full Name and last known address of any other person whose consent to this adoption is required:
Full Name: _____________________________________________________________
Complete Mailing Address: _____________________________________________________________
Town & State of Residence: _____________________________________________________________
Full Name: _____________________________________________________________
Complete Mailing Address: _____________________________________________________________
Town & State of Residence: _____________________________________________________________
Full Name: _____________________________________________________________
Complete Mailing Address: ______________________________________________________________
Town & State of Residence: _____________________________________________________________