Fillable Stepparent Adoption Request August 26, 2019 October 29, (California)

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Stepparent Adoption Request August 26, 2019 October 29, (California)

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Superior Court of California, County of Sacramento
Family Law & Probate
Stepparent Adoption Page 1 of 2
Cover Sheet:
Stepparent Adoption Request
Effective Date:
August 26, 2019
Last Revision Date:
October 29, 2020
Purpose:
These forms are used to start a Stepparent Adoption. Once filed,
this case can be used to obtain orders to amend the birth record to
add the stepparent and change the child’s name.
Assistance:
Parties who are acting as their own attorneys may receive help from
the Self Help Center to complete these forms. You may contact the
Self Help Center through the Court’s website, by creating an e-
Correspondence account.
Required Forms:
All forms are Judicial Council forms, unless otherwise indicated.
These forms are required in all cases:
•
Adoption Request, ADOPT-200
•
Parental Notification of Indian Status, ICWA-020
•
Indian Child Inquiry Attachment, ICWA-010(A)
•
Declaration Under Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA), FL-105
Adoption Agreement, ADOPT-210
•
Consent to Adoption by Parent Retaining Custody, CDSS
form AD 2
•
Investigation Questionnaire, local form FL/E-LP-647
•
Adoption Order, ADOPT-215
•
Court Report of Adoption, Vital Records form VS 44
These forms are required if they are applicable:
•
Notice of Child Custody Proceedings for an Indian Child,
ICWA-030
•
Consent to Adoption by Parent in or Outside California Giving
Custody to Husband or Wife or Domestic Partner of Other
Parent, CDSS form AD 2A/2B
Optional Forms:
This form may be used if it is applicable to your request:
•
Contact After Adoption Agreement, ADOPT-310
Filing Fee:
There is a $20 fee to file these documents and an additional $640
fee for the required adoption investigation. The current fee schedule
may be found on the Court’s website at:
https://www.saccourt.ca.gov/fees/docs/fee-schedule.pdf.
Copies:
Make two copies of the completed forms. The Court will file and
keep the original and will endorse and return the copies to you.
Before You File:
An original certified copy and two additional copies of each of the
following must be submitted with your Request:
•
Superior Court of California, County of Sacramento
Family Law & Probate
Stepparent Adoption Page 2 of 2
•
Birth Certificate of Child to be Adopted
•
Marriage License or Domestic Partnership Certificate
If applicable, an original certified copy and two additional copies of
each of the following must be submitted with your Request:
•
Death Certificate of Other Parent
•
Final Judgment of Dissolution for all prior marriages for either
the Petitioner or the Petitioner’s Spouse/Domestic Partner
•
Most recent court order awarding custody of the child to be
adopted
•
Order terminating parental rights
•
Order declaring minor free from parental custody and control
•
Proof of Donorship
•
Proof of Name Changes for biological parents, adoptive
parents, stepparents and/or child
Filing:
All forms must be typewritten or printed in blue or black ink. (See
California Rules of Court, Rules 2.100-2.119) Mail or place
completed forms in the court drop-box located at the Family Court at
3341 Power Inn Road, Sacramento, CA 95826. Drop box hours are
8:00 am to 5:00 pm Monday through Friday, excluding Court
holidays.
Next Steps:
To request a hearing, submit two copies of the court endorsed
Adoption Request along with a self-addressed, stamped envelope.
Adoption hearings are schedule on Monday morning at
8:30 a.m. If you have dates where you are unavailable print them on
the copy of the Adoption Request prior to submitting it to the court.
Once your filing is complete, you will be contacted by a Court
Investigator for an investigation to be completed. Once the
Investigation Report has been completed, a copy will be mailed to
you before the hearing date.
ADOPT-200
Adoption Request
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:
If you are adopting more than one child, fill out an adoption
request for each child.
1
Adopting parent(s)
a.
Name:
b.
Name:
Relationship to child:
Street address:
City:
State:
Zip:
Telephone number:
Lawyer (if any) (name, address, telephone numbers, e-mail address,
and State Bar number):
2
County of filing
This Adoption Request is filed in this court because (check all that apply):
The adopting parent or parents live in this county;
The child was born in or the child now lives in this county;
An office of the agency that placed the child for
adoption is located in this county;
An office of the department or public adoption agency
that is investigating the request is located in this county;
The placing birth parent or parents lived in this county
when the adoptive placement agreement, consent, or
relinquishment was signed;
The placing birth parent or parents lived in this county
when the request was filed;
The child was freed for adoption in this county.
(Note: 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 or parents reside. See Fam. Code, § 8714.)
(To be completed by the clerk of the superior court
if a hearing date is available.)
Hearing
Date
Hearing is set for:
Date:
Time:
Dept.:
Room:
Name and address of court if different from above:
To the person served with this request: If you do
not come to this hearing, the judge can order the
adoption without your input.
3
Type of adoption
Check one of the following:
Agency (name):
Relative Nonrelative
Tribal customary adoption (attach tribal customary adoption order)
Independent: Relative Nonrelative Additional Parent(s)
Intercountry (name of agency):
Stepparent adoption
Stepparent adoption to confirm parentage. See form to determine whether you are
eligible for the stepparent adoption to confirm parentage process.
Joinder:
Joinder is being filed at same time as this Adoption Request.
Joinder will be filed.
Judicial Council of California,
Rev. September 1, 2021, Mandatory Form
Family Code, §§ 170–180, 7660–7671, 7822, 7892.5, 7960, 8601.5,
8604, 8606, 8700, 8714, 8714.5, 8802, 8900–8905, 8908–8912,
8919, 8919.5, 8924, 8925, 9000, 9000.5, 9001, 9002, 9208;
Welfare and Institutions Code, §§ 366.24, 16119;
Cal. Rules of Court, rules 5.480–5.487, 5.493, 5.730
Adoption Request
ADOPT-200, Page 1 of 6
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
ADOPT-050-INFO
Your name:
Case Number:
4
Information about the child
a.
The child’s new name will be:
b.
Sex:
Female
Male
Nonbinary
c.
Date of birth: Age:
d.
Child’s address (if different from address of adopting parent or parents):
Street: City: State: Zip:
e.
Place of birth (if known):
City: State: Country:
f.
If the child is 12 or older, does the child agree to the adoption?
Yes
No
g.
Date child was placed in the physical care of the adopting parents:
h.
The child was conceived by assisted reproduction in compliance with Family Code section 7613.
i.
The child is a dependent of the court.
Juvenile Case No. County:
5
Child's name before adoption (fill out ONLY for independent, stepparent, or tribal customary adoption)
Child’s name before adoption:
6
Birth parents
Names of birth parents, if known:
7
Legal guardian
Does the child have a legal guardian?
Yes
No
(If yes, attach Letters of Guardianship and fill out below.)
a. Date guardianship ordered:
b.
County:
c.
Case number:
8 Inquiry and notice under the Indian Child Welfare Act
a.
The inquiry required under law to determine whether the child may be an Indian child has been made, and a
completed Indian Child Inquiry Attachment (form ICWA-010(A)) is attached.
Note: In agency adoptions, it is the responsibility of the agency to ensure that this inquiry is conducted and
the form is made part of the file. In independent adoptions, the adoption service provider, CDSS Regional
Office, or delegated county adoption agency is responsible.
b.
A completed version of Parental Notification of Indian Status (form ICWA-020) is attached OR a good
faith attempt has been made to provide the form to the parents, Indian custodian, or guardian of the child
and inform them that they are required to complete and submit the form to the court.
Note: In agency adoptions, it is the responsibility of the agency to ensure that these forms are made part of
the file. In independent adoptions, the adoption service provider, CDSS Regional Office, or delegated
county adoption agency is responsible.
c.
There is reason to know that this child is an Indian child. Notice of the adoption request will be provided
to the child’s tribe or tribes, parents, Indian custodian, and the Bureau of Indian Affairs, using Notice of
Child Custody Proceeding for Indian Child (form ICWA-030).
9
Adoption of an Indian child
a.
This is an adoption of an Indian child. The adopting parents have filled out and attached Adoption of Indian
Child (form ADOPT-220) and will bring Parent of Indian Child Agrees to End Parental Rights (form
ADOPT-225) to the hearing.
b.
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.
Rev. September 1, 2021
Adoption Request
ADOPT-200, Page 2 of 6
Your name:
Case Number:
10
Agency adoption questions
a.
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.
b.
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.
Yes No
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:
11
Independent adoption questions
a.
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.)
b. 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):
Yes
No
c.
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.
This is an independent adoption involving additional parent(s):
All persons with existing parental rights agree to this adoption and will maintain their existing parental
rights.
An agreement waiving termination of parental rights, signed by both the existing parent(s) and the
adopting parent(s) is attached.
12
Stepparent adoption and confirmation of parentage questions
a.
The birth parent (name):
has signed a consent will sign a consent.
b.
The birth parent (name):
has signed a consent will sign a consent.
c.
The adopting parent married or entered into a registered domestic partnership with the legal parent on (date):
. (For court use only. This does not affect social worker’s recommendation.
There is no waiting period.)
d.
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 or whose parentage was
established through a gestational surrogacy process, and we remain in that union. See attached:
Form ADOPT-205, Declaration Confirming Parentage in Stepparent Adoption
Form ADOPT-206, Declaration Confirming Parentage in Stepparent Adoption: Gestational Surrogacy
Declaration describing the circumstances of the child’s conception.
e.
The investigation or written report will be completed as follows (choose one):
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.
f.
This is a stepparent adoption involving an additional parent:
All persons with existing parental rights agree to this adoption and will maintain their existing parental
rights.
An agreement waiving termination of parental rights, signed by both the existing parent(s) and the
adopting parent(s) is attached.
Rev. September 1, 2021
Adoption Request
ADOPT-200, Page 3 of 6
Your name:
Case Number:
13
Intercountry adoption questions
a.
This adoption may be subject to the Hague Adoption Convention (form must be filed with
this request).
b.
This is an adoption conducted under the requirements of the Hague Adoption Convention and the child has
already moved with the adopting parent(s) to another Hague Convention member country or will be moving
at the conclusion of this adoption.
Child will be moving or has moved to (name of country):
Adopting parent(s):
seek(s) a California adoption
will be petitioning for a Hague Adoption Certificate
will be seeking a Hague Custody Declaration.
c.
This is an intercountry adoption that was finalized in another country before the child entered the United
States with the adopting parent(s).
Date the child entered the United States:
See form for a list of documents to attach to this Adoption Request.
14
Contact after adoption
Contact After Adoption Agreement ( )
is attached will not be used
will be filed at least 30 days before the adoption hearing
is undecided at this time.
This is a tribal customary adoption. Postadoption contact is governed by the attached tribal customary adoption
order.
15
Consent for adoption
Complete all sections that apply to your adoption:
a.
The consent of the birth parent is not necessary because (check the applicable reasons under Fam. Code,
§ 8606):
(1)
The parent has been judicially deprived of the custody and control of the child.
(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.
(3)
The parent has deserted the child without providing information to identify the child.
(4)
The parent has relinquished the child under Family Code section 8700.
(5)
The parent has relinquished the child for adoption to a licensed or authorized child-placing agency in
another jurisdiction.
b.
The child has a presumed parent under Family Code section 7611. The consent of the presumed parent is
not required because:
(1)
The presumed parent did not become a presumed parent before the mother’s relinquishment or
consent became irrevocable or the mother’s parental rights were terminated. (Fam. Code, § 8604(a).)
(2)
The presumed parent signed a Waiver of the Right to Further Notice of Adoption Proceedings
pursuant to Family Code section 7660.5.
c.
Termination of parental rights of an alleged father is not required because:
(1)
The relationship to the child was previously terminated or determined not to exist by a court.
(2)
The alleged father was served as prescribed in Family Code section 7666 with a written notice of alleged
parentage and the proposed adoption, and has failed to bring an action pursuant to Family Code section
7630(c) within 30 days of service of the notice or the birth of the child, whichever is later. (Attach proof
of notice to this Adoption Request.)
(3)
The alleged father has executed a written form to waive notice, deny parentage, relinquish the child
for adoption, or consent to the adoption of the child.
Rev. September 1, 2021
Adoption Request
ADOPT-200, Page 4 of 6
ADOPT-216
ADOPT-050-INFO
form ADOPT-310
Your name:
Case Number:
15
d.
A court ended the parental rights of:
Name: Relationship to child:
on (date):
Name: Relationship to child:
on (date):
(Enter the date of the court order ending parental rights and attach a copy of the order.)
e.
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 (attach a copy of the order):
Name: Relationship to child:
on (date):
Name: Relationship to child:
on (date):
Name: Relationship to child:
on (date):
f.
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):
Name: Relationship to child:
Name: Relationship to child:
g.
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).)
Name: Relationship to child:
Name: Relationship to child:
Name: Relationship to child:
h.
The child has been abandoned as follows:
(1)
The child has been left by the child’s parent or parents with no way to identify the child.
(2)
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.
(If any of the above boxes are checked, adopting parent must also check item 15f and file an Application for
Freedom From Parental Custody. See Fam. Code, § 7822(a).)
i.
Each of the following persons with parental rights has died:
Name: Relationship to child:
Name: Relationship to child:
16
Suitability for adoption
Each adopting parent:
a.
Is at least 10 years older than the child or meets the
criteria in Family Code section 8601(b);
b.
Will treat the child as their own;
c.
Will support and care for the child;
d.
Has a suitable home for the child; and
e.
Agrees to adopt the child.
Adoption Request
Rev. September 1, 2021
ADOPT-200, Page 5 of 6
Your name:
Case Number:
17
Requests to court
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):
for the following reason (Fam. Code, § 8601.5):
(Enter a date no earlier than the date parental rights were ended.)
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.
18
If a lawyer is representing you in this case, the lawyer must sign here:
Date:
Type or print lawyer’s name
Signature of lawyer for adopting parent(s)
19
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.
Date:
Type or print your name
Signature of adopting parent
Date:
Type or print your name
Signature of adopting parent
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).
Rev. September 1, 2021
Adoption Request
ADOPT-200, Page 6 of 6
1.
Relationship to child:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Form Adopted for Mandatory Use
Judicial Council of California
ICWA-020 [Rev. March 25, 2020]
PARENTAL NOTIFICATION OF INDIAN STATUS
Welfare & Institutions Code, § 224.2;
Family Code, § 177(a);
Probate Code, § 1459.5(b);
Cal. Rules of Court, rule 5.481
www.courts.ca.gov
Page 1 of 1
Name:
ICWA-020
ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO.:
EMAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CHILD'S NAME:
PARENTAL NOTIFICATION OF INDIAN STATUS
FOR COURT USE ONLY
CASE NUMBER:
To the parent, Indian custodian, or guardian of the above named child: You must provide all the requested information
about the child's Indian status by completing this form. If you get new information that would change your answers, you
must let your attorney, all the attorneys on the case, and the social worker or probation officer, or the court investigator
know immediately and an updated form must be filed with the court.
(SIGNATURE)
Date:
(TYPE OR PRINT NAME)
2.
Parent Indian custodian Guardian Other:
a. I am or may be a member of, or eligible for membership in, a federally recognized Indian tribe.
Name of tribe(s) (name each):
Location of tribe(s):
b. The child is or may be a member of, or eligible for membership in, a federally recognized Indian tribe.
Name of tribe(s) (name each):
Location of tribe(s):
3.
c. One or more of my parents, grandparents, or other lineal ancestors is or was a member of a federally recognized tribe.
Name of tribe(s) (name each):
Location of tribe(s):
Name and relationship of ancestor(s):
d. I am a resident of or am domiciled on a reservation, rancheria, Alaska Native village, or other tribal trust land.
e. The child is a resident of or is domiciled on a reservation, rancheria, Alaska Native village, or other tribal trust land.
f. The child is or has been a ward of a tribal court.
g. Either parent or the child possesses an Indian identification card indicating membership or citizenship in an Indian tribe.
A previous form ICWA-020 4.
has
has not
Note: This form is not intended to constitute a complete inquiry into Indian heritage. Further inquiry may be required by
the Indian Child Welfare Act.
Name of tribe(s) (name each):
Membership or citizenship number (if any):
Indian Status
h. None of the above apply.
been filed with the court.
3341 Power Inn Road
3341 Power Inn Road
Sacramento, CA 95826
William R. Ridgeway Family Relations Courthouse
(Check one)
5.
Based on inquiry and tribal contacts (check all that apply):
Form Adopted for Mandatory Use
Judicial Council of California
ICWA-010(A) [Rev. January 1, 2020]
INDIAN CHILD INQUIRY ATTACHMENT
www.courts.ca.gov
Page 1 of 1
Name of child:
I have not yet been able to complete the inquiry about the child's Indian status because:
(SIGNATURE)
Date:
(TYPE OR PRINT NAME)
ICWA-010(A)
CHILD'S NAME:
CASE NUMBER:
1.
2.
I understand that I have an affirmative and continuing duty to complete this inquiry. I will do it as soon as possible and
advise the court of my efforts.
I have asked or I am advised by and on information and belief confirm that
this person has completed inquiry by asking the child, the child's parents, and other required and available persons about
the child's Indian status. The person(s) questioned are:
Name:
Address:
City, state, zip:
Telephone:
Date questioned:
Relationship to child:
Name:
Address:
City, state, zip:
Telephone:
Date questioned:
Relationship to child:
Additional persons questioned and their information is attached.
This inquiry (check one):
3.
gave me reason to believe the child is or may be an Indian child. (If yes, continue to 4.)
gave me no reason to believe the child is or may be an Indian child.
4.
I contacted the tribe(s) that the child may be affiliated with and worked with them to establish whether the child is a
member or eligible for membership in the tribe(s). Information detailing the tribes contacted, the names of the individuals
contacted, and the manner of the contacts is attached.
a. The child is or may be a member of or eligible for membership in a tribe.
Name of tribe(s):
Location of tribe(s):
b. The child's parents, grandparents, or great-grandparents are or were members of a tribe.
Name of tribe(s):
Location of tribe(s):
c. The residence or domicile of the child, child's parents, or Indian custodian is on a reservation, rancheria, Alaska Native
village or other tribal trust land.
d. The child or the child's family has received services or benefits from a tribe or services that are available to Indians from
tribes or the federal government, such as the Indian Health Service or Tribal Temporary Assistance to Needy Families
(TANF).
e. The child is or has been a ward of a tribal court.
f. Either parent or the child possesses an Indian Identification card indicating membership or citizenship in an Indian tribe.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
If this is a delinquency proceeding under Welfare and Institutions Code section 601 or 602:
6.
The child is in foster care.
It is probable the child will be entering foster care.
Name of tribe(s):
Name of tribe(s):
Location of tribe(s):
Location of tribe(s):
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Additional children are listed on form
FL-105
(
A)/GC-120(A)
.
(Provide all requested information for additional children.)
FL-105/GC-120
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NUMBER:
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
1.
I am a party
to this proceeding to determine custody of a child.
2. My present address and the present address of each child residing with me is confidential under Family Code section 3429 as
I have indicated in item 3.
3. There are
(specify number):
(Insert the information requested below. The residence information must be given for the last FIVE years.)
a. Child’s name
Place of birth Date of birth Sex
Period of residence
Address
Relationship
Confidential
to present
to
to
to
b. Child’s name
Place of birth Date of birth Sex
Residence information is the same as given above for child a.
(If NOT the same, provide the information below.)
Period of residence
Address
Relationship
Confidential
to present
to
to
to
Additional residence information for a child listed in item a or b is continued on attachment 3c.
c.
Page 1 of 2
Family Code, § 3400 et seq.; Form Adopted for Mandatory Use
Judicial Council of California
FL-105/GC-120 [Rev. January 1, 2009]
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
Probate Code, §§ 1510(f), 1512
minor children who are subject to this proceeding, as follows:
www.courtinfo.ca.gov
TELEPHONE NO.:
FAX NO.
(Optional):
E-MAIL ADDRESS
(Optional):
ATTORNEY FOR
(Name):
ATTORNEY OR PARTY WITHOUT ATTORNEY
(Name, State Bar number, and address):
PETITIONER:
RESPONDENT:
GUARDIANSHIP OF
(Name):
Minor
OTHER PARTY:
Child's residence (
City, State)
Child's residence
(City, State)
Child's residence
(City, State)
d.
Child's residence (
City, State
)
Child's residence
(City, State)
Child's residence
(City, State)
(
This section applies only to family law cases.)
(This section apples only to guardianship cases.)
Confidential
Confidential
Sacramento
3341 Power Inn Road
3341 Power Inn Road
Sacramento, CA 95826
William R. Ridgeway Family Relations Courthouse
Juvenile Delinquency/
Juvenile Dependency
and provide the following information):
5. One or more domestic violence restraining/protective orders are now in effect.
(Attach a copy of the orders if you have one
a. Criminal
b. Family
d. Other
Court State Case number
(if known)
County Orders expire
(date)
Court
(name, state, location)
Court order
or judgment
(date)
Case status
b. Guardianship
c. Other
Name of each child
a. Family
Case number
Court
(name, state, location)
e. Adoption
Juvenile Delinquency/
Juvenile Dependency
Case Number
Your
connection to
the case
CASE NUMBER:
SHORT TITLE:
Do you have information about, or have you participated as a party or as a witness or in some other capacity in, another court case
or custody or visitation proceeding, in California or elsewhere, concerning a child subject to this proceeding?
Yes
(If yes, attach a copy of the orders (if you have one) and provide the following information):
Do you know of any person who is not a party to this proceeding who has physical custody or claims to have custody of or
visitation rights with any child in this case?
(If yes, provide the following information):
Yes
a. Name and address of person
b. Name and address of person
c. Name and address of person
Has physical custody
Has physical custody
Has physical custody
Claims custody rights
Claims custody rights
Claims custody rights
Claims visitation rights
Claims visitation rights
Claims visitation rights
Name of each child Name of each child Name of each child
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
7. Number of pages attached:
NOTICE TO DECLARANT: You have a continuing duty to inform this court if you obtain any information about a custody
FL-105/GC-120 [Rev. January 1, 2009]
Page 2 of 2
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
4.
6.
No
proceeding in a California court or any other court concerning a child subject to this proceeding.
No
FL-105/GC-120
Proceeding
Proceeding
c.
d.
ADOPT-210
Adoption Agreement
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:
1
Adopting parent(s)
a.
Name:
b.
Name:
Relationship to child:
Address (skip this if you have a lawyer):
City:
State:
Zip:
Telephone number:
Lawyer (if any) (name, address, telephone numbers, e-mail address,
and State Bar number):
2
Information about the child
Child’s name before adoption:
Child’s name after adoption:
Date of birth: Age:
Signing this form:
•
Adoptions usually require a hearing where most signatures on this form must be completed in front of a judge.
•
Item 4b may be signed before the hearing.
•
If this is a stepparent adoption to confirm parentage involving a spouse or registered domestic partner who gave
birth to the child or established parentage over a child born through gestational surrogacy during the union, usually
no hearing is required and you may sign this form in front of a proper witness. See item 8a for instructions on having
your signature properly witnessed. If the court orders a hearing in this case, you must sign this form at the hearing in
front of the judge.
•
All other signatures must be signed at a hearing, in front of a judge, unless waived by the judge for good cause.
3
I am the child listed in and I agree to the adoption. (Not required in the case of a tribal customary adoption
under Welf. & Inst. Code, § 366.24.)
2
Date:
Type or print your name
Signature of child (child must sign if 12 or older;
optional if child is under 12)
4
If there is only one adopting parent and that person is married and not separated, the consent of their spouse is
required under section 8603 of the Family Code. Read and sign below. Stepparent adoptions: Go to Item 7.
a.
I am the adopting parent listed in , and I agree that the child will:
1
(1)
Be adopted and treated as my legal child (Fam. Code, § 8612(b)) and
(2)
Have the same rights as a natural child born to me, including the right to inherit my estate.
Date:
Type or print your name
Signature of adopting parent
ADOPT-210, Page 1 of 3
Adoption Agreement
Judicial Council of California,
Rev. January 1, 2021, Mandatory Form
Family Code, §§ 8602–8606, 8612, 8919, 8919.5, 9000.5, 9003;
Welfare and Institutions Code, § 366.24;
Cal. Rules of Court, rule 5.730
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
Your name:
Case Number:
b. I am married to, or am the registered domestic partner of, the adopting parent listed in , and I am not a party
to this adoption. I agree to the adoption of the child by the adopting parent listed in .
1
1
Date:
Type or print your name
Signature of spouse or registered domestic partner
(may be signed before hearing)
5
If there are two adopting parents, read and sign below.
We are the adopting parents listed in , and we agree that the child will:
1
a.
Be adopted and treated as our legal child (Fam. Code, § 8612(b)) and
b.
Have the same rights as a natural child born to us, including the right to inherit our estate.
I agree to the other parent’s adoption of the child.
Date:
Type or print your name
Signature of adopting parent
I agree to the other parent’s adoption of the child.
Date:
Type or print your name
Signature of adopting parent
6
If this is a tribal customary adoption, read and sign below.
I/we are the adopting parents listed in , and I/we agree that the child will:
1
a.
Be adopted and treated as my/our legal child (Fam. Code, § 8612(b)) and
b.
Have the same rights and duties stated in the tribal customary adoption order dated
(copy
attached).
If two adopting parents, we agree to the other parent’s adoption of the child.
Date:
Type or print your name
Signature of adopting parent
Date:
Type or print your name
Signature of adopting parent
7
For stepparent adoptions only:
If you are the legal parent of the child listed in , read and sign below.
I am the legal parent of the child and am the spouse or registered domestic partner of the adopting parent listed in
. I agree to the adoption of my child by the adopting parent listed in .
2
1
1
Date:
Type or print your name
Signature of legal parent
ADOPT-210, Page 2 of 3
Adoption Agreement
Rev. January 1, 2021
Your name:
Case Number:
8
Executed (check one):
a.
This form was signed outside of a hearing. (Select this option only for a stepparent adoption to confirm
parentage under Family Code, § 9000.5, where the court did not order a hearing for good cause.)
(1)
This form was signed in California.
This form was signed in front of the following type of witness (check one):
Notary public (the notary acknowledgment is attached)
Court clerk
Probation officer
Qualified court investigator
Authorized representative of a licensed adoption agency
County welfare department staff member
(2)
This form was signed outside of California.
This form was signed in front of the following type of witness (check one):
Notary public (the notary acknowledgment is attached)
Other person authorized to perform notarial acts (proof of notarization is attached)
Authorized representative of an adoption agency that is licensed in the state or country where this
form was signed
(3)
Witness information
This form was signed in: (county) (state) (country)
Name of witness:
Agency witness works for (if applicable):
Date:
Witness signature:
b.
This form was signed at a hearing in front of a judicial officer. (The judge will date and sign the form below.)
Date:
Judge (or Judicial Officer)
ADOPT-210, Page 3 of 3
Adoption Agreement
Rev. January 1, 2021
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
Original for Court Record
Certified Copy for State Department of Social Services
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF
In the Matter of the Petition of
Petitioner
Name of Petitioner (Stepparent)
AD 2 (6/02)
STEPPARENT ADOPTION
Consent to Adoption by Parent
Retaining Custody
Name of Minor
I, the undersigned, being the parent of give my full and
free consent to the adoption of said child by , who is
my husband/wife/domestic partner without relinquishing any of my rights, duties, obligations as his/her parent, and I respectfully ask
that the petition be granted.
Said child was born on in and is the child
Date City and State
of and
Name of Legal Parent
Name of Legal Parent
Date 20
Signature of Parent
Signed in the presence of
*Title
* The Clerk of the Superior Court, the Probation Officer, or, where stepparent investigations are delegated to County Welfare
Departments, a County Welfare Department Staff member may witness.
This form for use only when person giving consent is husband or wife of petitioner or domestic partner, as defined in Family
Code Section 297, of petitioner.
Original for court record, certified copy to be sent immediately to California Department of Social Services, Sacramento.
}
FL/E-LP-647 (adopted 6/10; rev’d 2/17) Investigation Questionnaire Page 1 of 6
Mandatory
In the Superior Court of the State of California
In and for the County of Sacramento
INVESTIGATION QUESTIONNAIRE
FOR COURT USE ONLY
CASE NAME:
CASE NUMBER:
Instructions to Petitioner:
In order to facilitate a stepparent (or domestic partner) adoption or termination of parental rights, you must complete this questionnaire
and provide copies of the required documents as indicated to:
SACRAMENTO COUNTY SUPERIOR COURT
3341 Power Inn Road
Sacramento, CA 95826
The questionnaire is important in introducing you and your situation to the investigator handling your case. Attach all additional
documents as applicable to this questionnaire. The court will not file an incomplete packet or schedule a hearing date until all of the
necessary forms are completed and submitted to the court.
I. P E T I T I O N E R
Your current name: Driver’s License No.:
Maiden name and/or any other names used:
Name & telephone number of your attorney: ( )
Your current address
(Street, City, State and ZIP):
How long at this address? Years Months
Home Telephone: ( ) Business Telephone: ( )
If no home or business telephone, give a contact number where the investigator can reach you: ( )
II. I D E N T I F Y I N G D A T A O F P E T I T I O N E R
Social Security Number: Age: Date of Birth: Place of Birth:
Race: Eye Color: Hair Color: Wgt: Hgt:
Extent of schooling, H.S./College, etc.:
Insurance
(Life, Health, Car, etc.)
specify:
FL/E-LP-647 (adopted 6/10; rev’d 2/17) Investigation Questionnaire Page 2 of 6
Mandatory
III. M A R I T A L H I S T O R Y O F P E T I T I O N E R
(List all marriages)
Time
Name of spouse (use maiden
names) include present marriage
Date of Marriage Date Separated
Date & How Terminated Number of
Children
First
/ / / /
Second
/ / / /
Third
/ / / /
**Attach a certified copy of the current marriage license or Certificate of Registered Domestic Partnership**
**If applicable, attach a certified copy of the final divorce judgment of each previous marriage**
**If applicable, attach a certified copy of any orders changing your name**
IV. C H I L D
(List the child
INVOLVED
with this Court action)
Name Date of
Birth
Living with Address Name of
other parent
Indian Ancestry?
/ /
yes no
Has the child ever been involved in any other court case? Yes No
If so, what county ________________, case number _____________________.
**Attach certified copy of the birth certificate**
**If applicable, attach a certified copy of the Order of Adoption, if the minor has been previously adopted**
**If applicable, attach a certified copy of the most recent court order awarding custody of the child to be adopted or an Order Terminating**
Parental Rights or Order Declaring Minor Free from Parental Custody and Control
**If applicable, attach a certified copy of any orders changing the child’s name**
V. C H I L D R E N
(List all your other children
NOT INVOLVED
in the Court action)
Name Date of
Birth
Living with Address Name of other
parent
/ /
/ /
/ /
/ /
Since the separation of the parents of the minor(s), whom have the child(ren) been living with? Also list dates:
VI. H E A L T H O F C H I L D R E N
(List each child in this case who has recently been under the care of a Doctor, or Psychiatrist, including family physician)
/ /
/ /
/ /
/ /
FL/E-LP-647 (adopted 6/10; rev’d 2/17) Investigation Questionnaire Page 3 of 6
Mandatory
Do any of the children presently have physical or mental problems? Yes No If “Yes”, please explain:
Plan of custody/visitation:
Place of residence for self and children:
Will children be placed under supervision of others? Yes No If “Yes”, please complete below:
Name of caretaker: Relationship
to children
Address Phone Number What period of time
( )
( )
State the reasons why you feel the other parent should not have custody/visitation and be specific.
Give examples and dates (attach additional sheet, if needed).
VII. E M P L O Y M E N T
(Beginning with your present employment, list employment for the last 5 years)
Name of Employer Address of Employer Type of Job Date Begun Date Left Reason for Leaving
/ / / /
/ / / /
/ / / /
/ / / /
Current working hours and days:
M O N T H L Y I N C O M E Gross Net
From employment $ $
Own business $ $
Public Assistance
(AFDC or Social Security Assistance)
$ $
Child support $ $
Other sources $ $
TOTAL
$ $
Does the petitioner pay child support? Yes No
If yes, is the amount in the arrears? Yes No If yes, amount in arrears $_________
FL/E-LP-647 (adopted 6/10; rev’d 2/17) Investigation Questionnaire Page 4 of 6
Mandatory
VIII. M E D I C A L H I S T O R Y O F P E T I T I O N E R
(If either parent or guardian have any physical disability or have received psychiatric treatment or counseling, please complete the section below)
Name of Doctor & Address Name of Hospital & Address When Treated Nature of Illness
/ /
/ /
/ /
/ /
/ /
/ /
IX. C R I M I N A L R E C O R D O F P E T I T I O N E R
Does petitioner have a criminal record? Yes No If “Yes”, please give details:
Is petitioner on Probation or Parole? Yes No
If “Yes”, please give name of Probation Officer or Parole Agent: ______________________________________________
Area office: ( ) Phone number: ( )
Does the petitioner have any criminal actions pending: Yes No If “Yes”, please explain:
FL/E-LP-647 (adopted 6/10) Adoption Questionnaire Page 5 of 6
Mandatory
X. N A T U R A L F A T H E R
Name of natural father:
Date of last support:
Address:
Date of last contact with child:
Date of Birth:
Place of Birth: Race:
Occupation:
Employer:
Has he consented to Adoption: Yes No
Date of last contact with any other relative: / /
** If applicable, attach a certified copy of the death certificate, proof of parental rights being terminated, or orders changing father’s name **
M A R I T A L H I S T O R Y O F N A T U R A L F A T H E R
(List all marriages)
Time
Name of spouse (use maiden
names) include present marriage
Date of Marriage Date Separated
Date & How Terminated
Number of
Children
First
/ / / /
Second
/ / / /
Third
/ / / /
Is the child a result of a donorship? Yes No Is yes, attach proof of donorship.
FL/E-LP-647 (adopted 6/10) Adoption Questionnaire Page 6 of 6
Mandatory
XI. NATURAL MOTHER
Name of natural mother:
Date of last support:
Address:
Date of last contact with child:
Date of Birth:
Place of Birth: Race:
Occupation:
Employer:
Has she consented to Adoption: Yes No
Date of last contact with any other relative: / /
** If applicable, attach a certified copy of the death certificate, proof of parental rights being terminated, or orders changing mother’s name **
M A R I T A L H I S T O R Y O F N A T U R A L MOTHER
(List all marriages)
Time
Name of spouse (use maiden
names) include present marriage
Date of Marriage Date Separated
Date & How Terminated
Number of
Children
First
/ / / /
Second
/ / / /
Third
/ / / /
Before submitting your documents to the court, confirm that
you have attached all required documents to this packet
ADOPT-215
Adoption Order
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:
1
Adopting parent(s)
a.
Name:
b.
Name:
Relationship to child:
Street address:
City: State: Zip:
Daytime telephone number:
Lawyer (if any) (name, address, telephone number, e-mail address,
and State Bar number):
2
Information about the child
Child’s name after adoption:
First name:
Middle name:
Last name:
Date of birth: Age:
Place of birth (if known):
City:
State: Country:
3
Name of adoption agency (if any):
4
Hearing details
Hearing date:
Dept.: Div.: Rm.:
Judicial officer:
Clerk’s office telephone number:
People present at the hearing:
Adopting parent(s)
Lawyer for adopting parent(s)
Child
Child’s lawyer
Parent keeping parental rights:
Other people present (list each name and relationship to child):
a.
b.
If there are more names, attach a sheet of paper, write “ADOPT-215, Item 4” at the top, and list the
additional names and each person’s relationship to child.
The hearing is waived pursuant to Family Code section 9000.5 (Check this box only if this is an adoption confirming
parentage of a parent who was married to or in a state-registered domestic partnership, including a registered domestic
partnership or civil union from another jurisdiction, with the legal parent at the time the child was born.)
Judge will fill out section below.
5
The judge finds that the child
(check all that apply):
a.
Is 12 or older and agrees to the adoption
b.
Is under 12
c.
Is not required to consent because this is a tribal customary adoption.
ADOPT-215, Page 1 of 2
Adoption Order
Judicial Council of California,
Rev. January 1, 2021, Mandatory Form
Family Code, §§ 8601.5, 8612, 8714, 8714.5,
8900, 8900.5, 8902, 8912, 9000, 9000.5;
Welfare and Institutions Code, § 366.24;
Cal. Rules of Court, rule 5.730
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
Your name:
Case Number:
6
The judge has reviewed the report and other documents and evidence and finds that each adopting parent:
a.
Is at least 10 years older than the child or
meets the criteria in Fam. Code, § 8601(b);
b.
Will treat the child as their own;
c.
Will support and care for the child;
d.
Has a suitable home for the child; and
e.
Agrees to adopt the child.
7
This case is an adoption by a relative petitioned under Family Code section 8714.5.
The adopting relative The child, who is 12 or older,
has requested that the child’s name
before adoption be listed on this order. (Fam. Code, § 8714.5(g).)
The child’s name before adoption was:
First name: Middle name: Last name:
8
The child is an Indian child. The judge finds that this adoption meets the placement requirements of the
Indian Child Welfare Act or that there is good cause to give preference to these adopting parents. The clerk
will fill out below.
13
9
The judge approves the Contact After Adoption Agreement ( )
As submitted As amended on ADOPT-310
10
This is a tribal customary adoption. The tribal customary adoption order of the
tribe dated containing pages and attached hereto is fully incorporated into this order of adoption
.
11
This is an adoption under the Hague Adoption Convention. Verification of Compliance with Hague Adoption
Convention Attachment (form ADOPT-216) is attached and fully incorporated into this order.
12
This is an adoption involving an additional parent or parents. All persons with existing parental rights
agreed to this adoption and will maintain their existing parental rights.
An agreement waiving termination of
parental rights, signed by both the existing parent(s) and the adopting parent(s), was filed with the court.
13
The judge believes the adoption is in the child’s best interest and orders this adoption.
The child’s name after adoption will be:
First name:
Middle name:
Last name:
The adopting parent or parents and the child are now parent and child under the law, with all the rights and duties
of the parent-child relationship or, in the case of a tribal customary adoption, all the rights and duties set out in the
tribal customary adoption order and Welfare and Institutions Code section 366.24.
The judge believes it will serve public policy and the best interest of the child to grant the request of the
adopting parent or parents for the court to make this order effective as of (date): .
Date:
(Date of Signature)
Judge (or Judicial Officer)
Clerk will fill out section below.
14
Clerk’s Certificate of Mailing
For the adoption of an Indian child, the clerk certifies:
I am not a party to this adoption. I placed a filed copy of:
Adoption Request (form ADOPT-200)
Adoption of Indian Child (form ADOPT-220)
Adoption Order (form ADOPT-215)
Contact After Adoption Agreement (form ADOPT-310)
in a sealed envelope, marked “Confidential” and addressed to:
Chief, Division of Social Services
Bureau of Indian Affairs
1849 C Street, NW
Mail Stop 310-SIB
Washington, DC 20240
The envelope was mailed by U.S. mail, with full postage, from:
Place:
on (date):
Date:
Clerk, by:
, Deputy
ADOPT-215, Page 2 of 2
Adoption Order
Rev. January 1, 2021
ADOPT-310
COURT REPORT OF ADOPTION
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
OR ALTERATIONS
MOTHER
FACTS
OF
BIRTH
PARENTS'
DATA
1A. NAME OF CHILD-FIRST 1B. MIDDLE 1C. LAST (BIRTH)
2. SEX 3. DATE OF BIRTH-MM/DD/CCYY 4. NAME OF PHYSICIAN
(OR ATTENDANT, CERTIFIER, OR OTHER PERSON WHO ATTENDED THIS BIRTH)
FATHER
PARENT
5A. PLACE OF BIRTH--NAME OF HOSPITAL OR FACILITY 5B. CITY 5C. STATE OR COUNTRY
6A. FULL NAME OF PARENT--FIRST 6B. MIDDLE 6C. LAST (BIRTH)
7A. FULL NAME OF PARENT--FIRST 7B. MIDDLE 7C. LAST (BIRTH)
6D. RELATIONSHIP
7D. RELATIONSHIP
MOTHER
FATHER
PARENT
STATE FILE NUMBER LOCAL REGISTRATION NUMBER
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
PART I
The information provided in this section must be the information as it was at birth. Without this data, it may be
impossible to prepare a new Certificate of Birth.
Adoptive parents must furnish personal information about themselves as it was on the child's date of birth. This
information is used to prepare the new Certificate of Birth.
PART II
PARENT
INFORMATION
PARENT
INFORMATION
CHECK THE APPROPRIATE BOX: ADOPTIVE PARENT BIOLOGICAL PARENT
8C. LAST (BIRTH)8B. MIDDLE8A. NAME OF PARENT--FIRST
10. DATE OF BIRTH--MM/DD/CCYY9. STATE/FOREIGN COUNTRY OF BIRTH
CHECK THE APPROPRIATE BOX: ADOPTIVE PARENT BIOLOGICAL PARENT
11C. LAST (BIRTH)11B. MIDDLE11A. NAME OF PARENT--FIRST
13. DATE OF BIRTH--MM/DD/CCYY12. STATE/FOREIGN COUNTRY OF BIRTH
8D. RELATIONSHIP
MOTHER
FATHER
PARENT
11D. RELATIONSHIP
MOTHER
FATHER
PARENT
14. PLEASE CHECK ONE
15. Do you want the name of the hospital or other facility where birth occurred
omitted from the new birth certificate as provided for in Section 102645 of the
Health and Safety Code? (PLEASE CHECK ONE)
I want the original birth certificate sealed, and a new birth certificate established. . . . . . .
Pursuant to Health and Safety Code Section 102640, I choose not to have a new birth
certificate established. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES NO
VERIFICATION
OF PART II
AGENCY OR
DEPARTMENT
ATTORNEY
16. SIGNATURE OF PARENT VERIFYING DATA IN PART II 17. MAILING ADDRESS OF PARENT VERIFYING DATA IN PART II
18A. NAME OF AGENCY OR DEPARTMENT 18B. MAILING ADDRESS OF AGENCY/DEPARTMENT THAT INVESTIGATED/HANDLED THE ADOPTION
19A. SIGNATURE AND PRINTED NAME OF ATTORNEY 19B. MAILING ADDRESS OF ATTORNEY
The court clerk must obtain as much information as is available to complete Parts I and II before completing Part III
and forwarding the record and Court Order/Final Decree to the State Registrar as required by law.
PART III
COURT
CLERK
NAME AND
MAILING ADDRESS
OF PERSON TO
WHOM CERTIFIED
COPY IS TO BE
SENT
20. I HEREBY CERTIFY THAT THE INDIVIDUAL DESCRIBED ABOVE WAS ADOPTED BY THE ABOVE NAMED ADOPTIVE PARENTS ON THE DAY
OF , 20 , AS SET FORTH IN THE DECREE OF ADOPTION MADE ON THAT DATE IN CASE NUMBER
21A. NEW NAME AS SET FORTH IN THE DECREE
OF ADOPTION -- FIRST
21C. LAST21B. MIDDLE
22. SIGNATURE AND SEAL OF COURT CLERK BY:
23. CLERK IN AND FOR THE COUNTY OF: 24. DATE SIGNED--MM/DD/CCYY 25. DATE PETITION FOR ADOPTION FILED--MM/DD/CCYY
NAME
ADDRESS--Street and Number CITY, STATE, ZIP CODE DAYTIME TELEPHONE NUMBER
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS FORM VS 44 (Rev. 1/16)
GENERAL INFORMATION
The Court Clerk shall complete and transmit a court report of adoption to CDPH - Vital Records for each
decree of adoption granted by any court in the State of California.
CDPH - Vital Records shall transmit court reports of adoptions for births that occurred in another state, the
District of Columbia, any territory of the United States, or Canada to the appropriate registration authority.
The information contained in Part I and Part II of this certificate is required in order to identify and seal the
original birth certificate and prepare a new birth certificate. Once the original birth certificate is sealed, it is
only available upon order of a Superior Court.
The agency or department handling the adoption should fill out Parts I and II, but the Cout Clerk may
complete any incomplete items in Part I or Part II from the information furnished in the court record.
INSTRUCTIONS
When requested by the adoptive parents, the CDPH - Vital Records shall not establish a new birth
certificate for the child. (Health & Safety Code Section 102640.) The adoptive parents should indicate in Item
14 whether they DO want a new birth certificate established (by checking the "Yes" box) or whether they DO
NOT want a new birth certificate established (by checking the "No" Box).
The adoptive parents may request CDPH - Vital Records to omit the specific name and address of the
hospital or other facility where the birth occurred by checking the "Yes" Box in Item 15. (Health & Safety Code
Section 102645.)
A deceased spouse of an adopting single parent can be listed on the new birth certificate if both adopting
parents were in the home at the time of the initial placement of the child for adoption. Refer to Health & Safety
Code Section 102660 for additional requirements.
One of the adopting parents should verify the information in Part II, sign in Item 16, and enter his or her
mailing address in Item 17. The name and address of the agency or department and the attorney handling the
adoption should be entered in Items 18 and 19.
The applicable fee shall be paid to the Court Clerk at the time of filing the petition in an adoption proceeding
for the services required by statute of the State Registrar. (Health & Safety Code Section 103730.)
For cases in which the petition for adoption was filed on or after January 1, 1972, and the individual was
born in California or a foreign country, a certified copy of the new birth record will be furnished without additional
fee as provided in Health & Safety Code Section 102710.
For adoptions that occurred prior to January 1, 1972, or in another state, a fee must be submitted for
processing the new birth certificate, which includes one certified copy.
Additional certified copies may be obtained from CDPH - Vital Records, but there is an additional fee for
each additional certified copy requested. Please contact CDPH - Vital Records for the current fees, or visit our
website at www.cdph.ca.gov. Please do not order additional copies until you have reviewed the original copy
for accuracy. The mailing address for CDPH - Vital Records is:
California Department of Public Health - Vital Records
MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
ICWA-030
CONFIDENTIAL
FOR COURT USE ONLY
CASE NUMBER:
HEARING DATE:
DEPT.:
ATTORNEY OR PARTY WITHOUT ATTORNEY
STATE BAR NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE:
ZIP CODE:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NAME:
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD (check all that apply):
JUVENILE Dependency Delinquency
ADOPTION CONSERVATORSHIP
CUSTODY (Fam. Code, § 3041)
DECLARATION OF FREEDOM FROM CONTROL OF PARENT
GUARDIANSHIP
TERMINATION OF PARENTAL RIGHTS
VOLUNTARY RELINQUISHMENT
OF CHILD BY PARENT
NOTICE TO (check all that apply):
Parents or Legal Guardians Tribes Sacramento Area Director, BIA Indian Custodians
1. NOTICE is given that based on the petition, a copy of which is attached to this notice, a child custody proceeding under the Indian
Child Welfare Act (25 U.S.C. § 1901 et seq.) has been initiated for the following child (a separate notice must be filed for each child):
Name
Date of Birth Place of Birth
2. HEARING INFORMATION
a. Date: Time: Dept.: Room:
Type of hearing:
b. Address and telephone number of court same as noted above
is (specify):
3.
The child is or may be eligible for membership in the following Indian tribes (list each):
*
Use this form in a conservatorship only if the proposed conservatee is a formerly married minor.
Page 1 of 10
Form Adopted for Mandatory Use
Judicial Council of California
ICWA-030 [Rev. January 1, 2021]
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
25 U.S.C. § 1901 et seq.;
Welfare & Institutions Code, §§ 224.2, 224.3;
Probate Code, §§ 1449, 1459.5; 1460.2;
Cal. Rules of Court, rules 5.480–5.487 and 7.1015
Sacramento
3341 Power Inn Road
3341 Power Inn Road
Sacramento, CA 95826
William R. Ridgeway Family Relations Courthouse
CASE NAME:
CASE NUMBER:
ICWA-030
4. Under the Indian Child Welfare Act (ICWA) and California law:
a.
The child's parents, Indian custodian, and the child's tribe have the right to be present at all hearings.
b.
The child's Indian custodian and the child's tribe have the right to intervene in the proceedings when ICWA applies.
c.
The child's parent, Indian custodian, or tribe may petition the court to transfer the case to the tribal court of the Indian child's
tribe. The child's parent or tribe also have the right to refuse to have the case transferred to the tribal court.
d.
With the limited exceptions of the detention hearing in juvenile cases and the jurisdiction and disposition hearings in delinquency
cases as identified in rule 5.482, the court will give up to 20 additional days from the time of the scheduled hearing if the child's
parent, Indian custodian, or tribe request such time to prepare for the hearing.
e.
The proceedings could lead to the removal of the child from the custody of the parent or Indian custodian and possible
termination of parental rights and adoption of the child.
f.
If the child's parents or Indian custodian have a right to be represented by a lawyer and if they cannot afford to hire one, a
lawyer will be appointed for them.
g.
The information contained in this notice and all attachments is confidential. Any tribal representative or agent or any other
person or entity receiving this information must maintain the confidentiality of this information and not reveal it to anyone who
does not need the information in order to exercise the tribe's rights under the Indian Child Welfare Act (25 U.S.C. § 1901 et
seq.).
h.
An Indian custodian is any Indian person who has legal custody of the child under tribal law or custom or state law, or to whom
temporary physical custody, care, and control of the child has been transferred by a parent.
5. INFORMATION ON THE CHILD NAMED IN 1
a.
A copy of the petition initiating this case is attached.
b.
The child's birth certificate is
attached unavailable.
c.
A copy of the tribal registration card of the child the parent is attached.
d. Biological relative information is listed below. (Indicate if any of the information requested below is unknown or does not apply.
Do not use the abbreviation "N/A".) (Required by Fam. Code, § 180; Prob. Code, § 1460.2; and Welf. & Inst. Code, § 224.3.)
e.
If the chart does not represent the gender identities of the individuals in the child's family tree, please attach an
appropriate equivalent.
Biological Mother
Biological Father
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Additional information:
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
Additional information:
If deceased, date and place of death:
ICWA-030 [Rev. January 1, 2021]
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
Page 2 of 10
CASE NAME:
CASE NUMBER:
ICWA-030
5. f. INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)
Mother's Biological Mother
(Child's Maternal Grandmother)
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Father's Biological Mother
(Child's Paternal Grandmother)
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Mother's Biological Father
(Child's Maternal Grandfather)
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Father's Biological Father
(Child's Paternal Grandfather)
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Page 3 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
5.
Mother's Biological Grandfather
(Child's Maternal Great-grandfather)
INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)
g.
Mother's Biological Grandmother
(Child's Maternal Great-grandmother)
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Mother's Biological Grandmother
(Child's Maternal Great-grandmother)
Mother's Biological Grandfather
(Child's Maternal Great-grandfather)
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Page 4 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
5. h. INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)
Father's Biological Grandmother
(Child's Paternal Great-grandmother)
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Father's Biological Grandmother
(Child's Paternal Great-grandmother)
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Father's Biological Grandfather
(Child's Paternal Great-grandfather)
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Father's Biological Grandfather
(Child's Paternal Great-grandfather)
Name (include former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:
Page 5 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
5. INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A")
i.
Information on Indian Ancestry of
Other Lineal Biological Ancestors
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
Information on Indian Ancestry of
Other Lineal Biological Ancestors
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
If deceased, date and place of death:If deceased, date and place of death:
More information on lineal biological ancestors is attached on a separate sheet.
5. j. INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)
Indian Custodian Information
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
Indian Custodian Information
Name (include maiden, married, and former names or aliases):
Current address:
Former address:
Birthdate and place:
Tribe or band, and location:
Tribal membership or enrollment number, if known:
Page 6 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
6. ADDITIONAL INFORMATION ON THE CHILD NAMED IN 1
(Indicate if any of the information requested below is unknown.)
a.
Biological father is named on birth certificate. Unknown
b.
Biological father has acknowledged parentage. Unknown
c.
There has been a judicial declaration of parentage. Unknown
d. Other alleged father
(name each):
Unknown
The following optional questions may be helpful in tracing the ancestry of the child named in 1.
7.
Has the child named in 1 or any members of the child's family ever (if "yes," provide the information requested below):
a. Attended an Indian school? UnknownNoYes
Name/relationship to child Type of school Dates attended Name and location of school
b. Received medical treatment at an Indian health clinic or U.S. Public Health Service hospital?
UnknownNoYes
Name/relationship to child Type of treatment Dates of treatment Location where treatment given
c. Lived on federal trust land, a reservation, rancheria, an allotment or in an Alaska Native village or other tribal trust land?
UnknownNoYes
Name/relationship to child Name/description of property and address Dates of residence
d.
Other relative information (e.g., aunts, uncles, siblings, first and second cousins, stepparents, etc.)
Name/relationship to child Current and former address Birthdate and place Tribe, band, and location
8.
Tribal affiliation and location of child named in 1 (check all that apply):
a.
1906 Final Roll Name of relative listed on roll:
Relationship to child named in 1:
b.
Roll of 1924 Name of relative listed on roll:
Relationship to child named in 1:
c.
California Judgment Roll. Name of relative listed on roll:
Relationship to child named in 1:
Page 7 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
9.
Additional party information (list the name, mailing address, and telephone number of all parties notified):
Name
Mailing Address Telephone Number
DECLARATION
(To be completed, dated, and signed in all cases by each petitioner named in companion petition.)
I am the petitioner or we are all of the petitioners in this proceeding. In response to items 5–9 of this form, I/we have given all
information I/we have about the relatives and, if applicable, the Indian custodian, of the child named in item 1 of this form.
I/We declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and
correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE)
Date:
(TYPE OR PRINT NAME) (SIGNATURE)
Date:
(TYPE OR PRINT NAME) (SIGNATURE)
Page 8 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
CERTIFICATE OF MAILING—JUVENILE COURT PROCEEDINGS
(To be completed by social worker or probation officer.)
I certify that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition identified on page 1 of this
form, was mailed as follows. Each copy was enclosed in an envelope with postage for registered or certified mail, return receipt
requested, fully prepaid. The envelopes were addressed to each person, tribe, or agency as indicated below. (Except that the
telephone numbers shown below were not placed on the envelopes. They are shown below because they must be disclosed in the
Notice under Family Code section 180, Probate Code section 1460.2, and Welfare and Institutions Code section 224.3.) Each
envelope was sealed and deposited with the United States Postal Service at
(place):
on (date):
.
Date: Title: Department:
(TYPE OR PRINT NAME)
(SIGNATURE)
DECLARATION OF MAILING—ADOPTION, FAMILY LAW, AND PROBATE PROCEEDINGS
(To be completed by the attorney for Petitioner if Petitioner is represented.)
I am an attorney at law, admitted to practice in the courts of the State of California, and attorney for Petitioner in this matter.
I declare that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition identified on page 1 of
this form, was mailed as follows. Each copy was enclosed in an envelope with postage for registered or certified mail, return
receipt requested, fully prepaid. The envelopes were addressed to each person, tribe, or agency as indicated below. (Except that
the telephone numbers shown below were not placed on the envelopes. They are shown below because they must be disclosed
in the Notice under Family Code section 180, Probate Code section 1460.2, and Welfare and Institutions Code section 224.3.)
Each envelope was sealed and deposited with the United States Postal Service at
(place):
on (date):
.
I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE)
CERTIFICATE OF MAILING—PROBATE PROCEEDINGS
(To be completed by the clerk of the court if Petitioner is unrepresented.)
I certify that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition, was mailed as follows. Each
copy was enclosed in an envelope with postage for registered or certified mail, return receipt requested, fully prepaid. The envelopes
were addressed to each person, tribe, or agency as indicated below. (Except that the telephone numbers shown below were not
placed on the envelopes. They are shown below because they must be disclosed in the Notice under Family Code section 180,
Probate Code section 1460.2, and Welfare and Institutions Code section 224.3.) Each envelope was sealed and deposited with the
United States Postal Service at
(place): on (date):
.
Date: Title: Department:
(TYPE OR PRINT NAME)
(SIGNATURE)
This form and all return receipts must be filed with the court.
Page 9 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
CASE NAME:
CASE NUMBER:
ICWA-030
NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS,
TRIBES, OR AGENCIES TO WHOM NOTICE WAS MAILED
1.
Parent
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
2.
Parent
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
3. Guardian
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
4. Guardian
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
5.
Indian Custodian
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
6.
Indian Custodian
(Name):
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
Sacramento Regional Director
Bureau of Indian Affairs, Federal Office Building
7.
Street address:
City, state, and zip code:
Telephone number:
8. Tribe
(Name):
Addressee (Name):
Title:
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
9. Tribe
(Name):
Addressee (Name):
Title:
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
10. Tribe
(Name):
Addressee (Name):
Title:
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
11. Tribe
(Name):
Addressee (Name):
Title:
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
12. Tribe
(Name):
Addressee (Name):
Title:
Street address:
Mailing address:
City, state, and zip code:
Telephone number:
Note: Notice to the tribe must be sent to the tribal chairperson or designated authorized agent for service.
Additional tribes served listed on attached form ICWA-030(A)
Page 10 of 10
NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)
ICWA-030 [Rev. January 1, 2021]
2800 Cottage Way
Sacramento, CA 95825
IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF
In the Matter of the Petition of
STEPPARENT ADOPTION
}
Petitioner
Consent to Adoption by a Parent in or outside
of California Giving Custody to Husband or Wife
or Domestic Partner of Other Parent
I, being the parent of
Name of Minor child
Do hereby give my full and free consent to the adoption of said child by
,
Name of Petitioner (Stepparent)
The petitioner herein, it being fully understood by me that with the signing of this document my consent may
not be withdrawn except with court approval and that with the signing of the order of adoption by the court,
I shall give up all my rights of custody; services, and earning of said child, and that said child cannot be
reclaimed by me.
DATESIGNATURE OF NOTARY
SIGNATURE OF WITNESS
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AD 2A/2B (05/11)
SIGNED IN COUNTY/STATE
NAME OF AGENCY
TITLE OF WITNESSNAME OF WITNESS
DATE
Said child was born on
Date City and State
And is the child of
Name of Birth Parent Name of Birth Parent
DATE
Signature of Parent
WITNESS BY:
If this form is being signed in the State of California the Clerk of the Superior Court, the Probation Officer,
qualified court investigator or; where stepparent investigations are delegated to County Welfare
Departments, a County Welfare Department Staff member may witness. [Family Code § 9003]
If this form is being signed outside the State of California only a notary or other person authorized to
perform notary acts within that state can witness.
COMPLETED BY NOTARY PUBLIC
Complete this section when the form is not being signed in the presence of an agency representative.
The Notary Public must staple the acknowledgement document to this form and sign and date.
NOTICE TO THE BIRTH PARENT WHO CONSENTS TO THE CHILD’S ADOPTION: If you and your
child lived together at any time as parent and child, the adoption of your child by a stepparent does not
affect the child’s right to inherit your property or the property of blood relatives. For further information
regarding this right of inheritance, you should consult an attorney at your own expense.
This form to be used only when parent is giving custody of the child to the husband or wife or domestic
partner, as defined in Family Code Section 297, or other parent. Original for court record.
and
in
(Gender: M F)
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:
ADOPT-310
Contact After Adoption Agreement
Original Change
Child’s name (after adoption):
Age:
Phone number:
2
Your name(s):
Relationship to child:
Street:
State: Zip:City:
a.
b.
Your phone number:
Name of child’s lawyer:
Address:
City:
1
3
ADOPT-310, Page 1 of 2
Contact After Adoption Agreement
Judicial Council of California, www.courts.ca.gov
Revised January 1, 2018, Mandatory Form
Family Code, §§ 8616.5, 8714.5;
Welfare and Institutions Code, § 366.26
Your address (skip this if you have a lawyer)
Your lawyer, (if you have one) (name, address, phone number, and
State Bar number):
Information about the child
a.
b.
Date of birth:
c.
Is the child a dependent of Juvenile Court?
No Yes
If yes, Juvenile Court and Juvenile Case number:
Case #:
County:
d.
If the child has a lawyer, fill out below. If item 2c is yes, child must have a lawyer (Fam. Code, § 8714.7).
State: Zip:
State Bar number:
The people below agree with the requesting party(ies) in about contact with the child after adoption. If the
agreement is confidential, write “Confidential” instead of the person’s name.
1
If you need more space, attach a sheet of paper. Write “ADOPT-310,
Item 3—Other Relatives” at the top.
Type of Contact (circle all that apply):
(
Telephone * Letter H Visits
1 Share Info : E-mail s Other*
( * H 1 : s
( * H 1 : s
( * H 1 : s
( * H 1 : s
( * H 1 : s
( * H 1 : s
( * H 1 : s
*Explain type of contact on a sheet of paper. Write “ADOPT-310, Item 3—Other Types of Contact” at the top.
Number of pages attached:
a.
g.
f.
e.
d.
c.
b.
Name Relationship to Child
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
The parties have discussed the reasons for continued contact between the child and the specified relatives or other
parties, considering the best interests of the child.
Date:
Type or print your name and relationship to child
Your name:
Case Number:
ADOPT-310,
Page 2 of 2
Contact After Adoption Agreement
Revised January 1, 2018
4
If you have a signed, written agreement about Contact After Adoption, attach a copy.
Number of pages attached:
5
Notice
1. After the judge signs the Adoption Order for this child, the adoption is final. It can never be cancelled
or changed, even if anyone who signed this agreement:
• Does not follow the agreement, and/or
• Files ADOPT-315 (to change, end, or enforce this agreement).
2. Before this agreement can be changed by the court, all of the people who signed it have to try to fix any
problems with it through a dispute resolution program, like mediation.
6
Everyone involved in this agreement must sign below (including the child, if 12 or older, and the child’s attorney).
Date:
Type or print your name and relationship to child
Date:
Type or print your name and relationship to child
Date:
Type or print your name and relationship to child
Date:
Type or print your name and relationship to child
Date:
Type or print your name and relationship to child
If more relatives need to sign, attach a sheet of paper. Write “ADOPT-310, Item 6—Signatures of Other Relatives,”
at the top.
Number of pages attached:
Date:
Judge (or Judicial Officer)
Sign your name
Sign your name
Sign your name
Sign your name
Sign your name
Sign your name
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Stepparent Adoption Request August 26, 2019 October 29, (California)

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Completed 3 April 2022

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