INDEX TO APPENDIX


ORPHANS’ COURT AND REGISTER OF WILLS FORMS
ADOPTED BY SUPREME COURT
PURSUANT TO Pa. O.C. Rule 1.8



Available as Fill-in Forms on Website
of Administrative Office of Pennsylvania Courts
http://www.pacourts.us/forms/for-the-public/orphans-court-forms

Orphans’ Court and Administration Forms

 A.  Audit and Administration Forms

   1.  Decedent’s Estate: Petition for Adjudication/Statement of
Proposed Distribution Pursuant to Pa. O.C. Rule 2.4…OC-01

   2.  Trust: Petition for Adjudication/Statement of Proposed
Distribution Pursuant to Pa. O.C. Rule 2.4…OC-02

   3.  Guardianship of Incapacitated Person: Petition for
Adjudication/Statement of Proposed Distribution Pursuant to
Pa. O.C. Rule 2.4…OC-03

   4.  Guardianship of Minor: Petition for Adjudication/Statement of
Proposed Distribution Pursuant to Pa. O.C. Rule 2.4…OC-04

   5.  Principal’s Estate (Under Power of Attorney): Petition for
Adjudication/Statement of Proposed Distribution Pursuant to
Pa. O.C. Rule 2.4…OC-05

   6.  Notice of Charitable Gift (In Accordance with Pa. O.C.
Rule 4.4)…OC-06

   7.  Notice of Claim…OC-07

 B.  Guardianship Forms

   1.  Important Notice—Citation with Notice (Pa. O.C. Rule 14.2)… G-01

   2.  Report of Guardian of the Estate… G-02

   3.  Report of Guardian of the Person… G-03

   4.  Guardian’s Inventory for a Minor… G-04

   5.  Guardian’s Inventory for an Incapacitated Person … G-05

   6.  Guardianship of Incapacitated Person: Petition for
Adjudication/Statement of Proposed Distribution Pursuant to
Pa. O.C. Rule 2.4…OC-03*

   7.  Guardianship of Minor: Petition for Adjudication/Statement
of Proposed Distribution Pursuant to Pa. O.C. Rule 2.4…OC-04**

   * Form OC-3 is not reprinted here and is located under Audit and Administration Forms at No. 3.

   ** Form OC-4 is not reprinted here and is located under Audit and Administration Forms at No. 4.

 C.  Abortion Control Act Forms

   1.  Minor’s Application for Judicial Authorization of an Abortion
(Pa. O.C. Rule 16.10)…ACA-01

   2.  Confidential Unsworn Verification by a Minor (Pa. O.C.
Rule 16.10)… ACA-02

 D.  Register of Wills Forms

   1.  Estate Information Sheet… RW-01

    (Not adopted by Supreme Court; form promulgated by Department of Revenue and maintained with Register of Wills forms for convenience)

   2.  Petition for Grant of Letters… RW-02

   3.  Oath of Subscribing Witness(es)… RW-03

   4.  Oath of Non-subscribing Witness(es)… RW-04

   5.  Oath of Witness(es) to Will Executed by Mark… RW-05

   6.  Renunciation… RW-06

   7.  Notice of Estate Administration Pursuant to Pa. O.C.
Rule 10.5…RW-07

   8.  Certification of Notice under Pa. O.C. Rule 10.5…RW-08

   9.  Inventory… RW-09

   10.  Pa. O.C. Rule 10.6 Status Report… RW-10

 E.  Model Forms of Account

   1.  National Fiduciary Accounting Standards Project—1983
Report of Fiduciary Accounting Standards Committee

   2.  Model Estate Account

   3.  Model Trust Account

   4.  Model Charitable Remainder Unitrust Account

 F. Adoption Forms

   1.  Notice of Orphans’ Court Proceedings to be Filed With Clerk in
Dependency Proceeding by Solicitor of County Agency (Pa. O.C.
Rule 15.6(b)

     a.   Praecipe to Clerk in Dependency Proceeding of Filing of a Petition to Terminate Parental Rights, Confirm Consent, or Adopt

     b.   Praecipe to Clerk in Dependency Proceeding of Entry of Decision Disposing of Petition

     c.   Praecipe to Clerk in Dependency Proceeding of Filing of Notice of Appeal

     d.   Praecipe to Clerk in Dependency Proceeding of Entry of Decision Disposing of Appeal

   2.  Foreign Adoption Forms

     a.   Form for Registration of Foreign Adoption Decree (Pa. O.C. Rule 15.8), including Instructions for Filing Petition, Petition to Register Foreign Adoption Decree, and Proposed Final Decrees

     b.   Form Petition for Adoption of a Foreign Born Child (Pa. O.C. 15.9), including the Petition for Adoption of a Foreign Born Child, Report of the Intermediary, Verification of Translator, Preliminary Decree, and Final Decree

   Source

 The provisions of this Appendix adopted October 16, 2006, effective 30 days from the date of entry of this order, 36 Pa.B. 6760; amended March 29, 2007, effective 30 days from the date of entry of this order; amended January 3, 2011, effective in sixty days, 41 Pa.B. 336; amended October 11, 2011, effective in thirty days, 41 Pa.B. 5743; amended March 19, 2013, effective April 19, 2013 for all termination and adoption petitions filed after that date, 43 Pa.B. 1836; amended August 9, 2016, effective September 1, 2016, 46 Pa.B. 5479; amended June 1, 2018, effective July 1, 2018, 48 Pa.B. 3524. Immediately preceding text appears at serial pages (383149) to (383318).

 (Editor’s Note: Supreme Court Order No. 770 (June 1, 2018) amended Orphans’ Court Form G-01, and adopted Orphans’ Court Forms G-06 and G-07, effective June 1, 2019. See 48 Pa.B. 3524 (June 16, 2018).)

   

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

   

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

DECEDENT’S ESTATE

TRUST

TRUST

TRUST

TRUST

TRUST

TRUST

TRUST

TRUST

TRUST

TRUST

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF INCAPACITATED PERSON

GUARDIANSHIP OF MINOR

GUARDIANSHIP OF MINOR

GUARDIANSHIP OF MINOR

GUARDIANSHIP OF MINOR

GUARDIANSHIP OF MINOR

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

PRINCIPAL’S ESTATE

   

NOTICE OF CHARITABLE GIFT

   

NOTICE OF CHARITABLE GIFT

   

NOTICE OF CHARITABLE GIFT

   

NOTICE OF CHARITABLE GIFT

NOTICE OF CLAIM

CITATION WITH NOTICE

CITATION WITH NOTICE

GUARDIAN OF THE ESTATE

GUARDIAN OF THE ESTATE

GUARDIAN OF THE ESTATE

GUARDIAN OF THE ESTATE

GUARDIAN OF THE ESTATE

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN OF THE PERSON

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

GUARDIAN’S INVENTORY

AUTHORIZATION OF AN ABORTION

AUTHORIZATION OF AN ABORTION

CONFIDENTIAL VERIFICATION

CONFIDENTIAL VERIFICATION

ESTATE INFORMATION SHEET

PETITION FOR PROBATE AND GRANT OF LETTERS

PETITION FOR PROBATE AND GRANT OF LETTERS

OATH OF SUBSCRIBING WITNESS(ES)

OATH OF NON-SUBSCRIBING WITNESS(ES)

OATH OF WITHNESS(ES) TO WILL EXECUTED BY MARK

RENUNCIATION

NOTICE OF ESTATE ADMINISTRATION

CERTIFICATION OF NOTICE UNDER Pa.O.C. Rule 5.6(a)

INVENTORY

Pa.O.C. Rule 6.12 STATUS REPORT

1983 REPORT OF FIDUCIARY ACCOUNTING STANDARDS COMMITTEE

Performance Accounting Distinguished

Model Accounts

II. A fiduciary account shall begin with a concise summary of its purpose and content.

Illustrations:

IV. A fiduciary account shall include both carrying values—

The value of assets at the beginning and ending of each accounting period

V. Gains and losses incurred during the acounting period shall be shown separately in the same schedule.

Model Estate Account

SUMMARY OF ACCOUNT

PRINIPAL RECEIPTS

PRINCIPAL RECEIPTS (cont’d)

PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITION

DISBURSEMENTS OF PRINCIPAL

DISBURSEMENTS OF PRINCIPAL (cont’d)

DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES

PRINCIPAL BALANCE ON HAND

PRINCIPAL INVESTMENTS MADE

CHANGES IN PRINCIPAL HOLDINGS

RECEIPTS OF INCOME

DISBURSEMENTS OF INCOME

DISTRIBUTIONS OF INCOME TO BENEFICIARIES

VERIFICATION

Model Trust Account

SUMMARY OF ACCOUNT

PRINCIPAL RECEIPTS

PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITIONS

PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITIONS (cont’d)

DISBURSEMENTS OF PRINCIPAL

DISBURSEMENTS OF PRINCIPAL (cont’d)

DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES

PRINCIPAL BALANCE ON HAND

PRINCIPAL INVESTMENTS MADE

CHANGES IN PRINCIPAL HOLDINGS

CHANGES IN PRINCIPAL HOLDINGS (cont’d)

CHANGES IN PRINCIPAL HOLDINGS (cont’d)

RECEIPTS OF INCOME

DISBURSEMENTS OF INCOME

DISTRIBUTIONS OF INCOME TO BENEFICIARIES

INCOME BALANCE ON HAND

VERIFICATION

Model Charitable Remainder Unitrust Account

SUMMARY OF ACCOUNT

PRINCIPAL RECEIPTS

PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITIONS

DISBURSEMENTS OF PRINCIPAL

PRINCIPAL BALANCE ON HAND

PRINCIPAL INVESTMENTS MADE

CHANGES IN PRINCIPAL HOLDINGS

CHANGES IN PRINCIPAL HOLDINGS (cont’d)

RECEIPTS OF INCOME

RECEIPTS OF INCOME (cont’d)

RECEIPTS OF INCOME (cont’d)

RECEIPTS OF INCOME (cont’d)

RECEIPTS OF INCOME (cont’d)

RECEIPTS OF INCOME (cont’d)

RECEIPTS OF INCOME (cont’d)

DISBURSEMENTS OF INCOME

DISTRIBUTIONS OF INCOME TO BENEFICIARIES

DISTRIBUTIONS OF INCOME TO BENEFICIARIES (cont’d)

INCOME BALANCE ON HAND

UNITRUST STATEMENT 2001

UNITRUST STATEMENT 2002

UNITRUST STATEMENT 2003

UNITRUST STATEMENT 2003 (cont’d)

UNITRUST STATEMENT 2004

UNITRUST STATEMENT 2004 (cont’d)

UNITRUST STATEMENT 2005

UNITRUST STATEMENT 2005 (cont’d)

VERIFICATION

IN THE COURT OF COMMON PLEAS



COUNTY, PENNSYLVANIA


ORPHANS’ COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)


IN RE: FOREIGN ADOPTION OF


FILE NO.


PETITION TO REGISTER FOREIGN ADOPTION DECREE
PURSUANT TO 23 Pa.C.S. §  2908

 1. Petitioner(s), the Adopting Parent(s) of the above-named adopted child, is/are







 2. Petitioner(s) reside(s) in


County, Pennsylvania, at



        (Street Address)



        (City, State, Zip)

 3. Has any other court in this Commonwealth or in any other state reviewed, registered, finalized or otherwise assumed jurisdiction over the foreign adoption decree being registered here:
(circle one)    Yes    No

 If yes, please provide the name of the court, the state and county, what was previously presented to the court and the resulting decision from the court:
(Attach all court decrees).

   



   



   



   



 4. The full name of the adopted child at birth as listed on the foreign birth certificate, if available, was




.

 5. The full name of the adopted child as written on the foreign adoption decree is


.

 6. The full name of the adopted child as he or she is to be known from this time forward is




.

 7. The date of birth of the adopted child is


.

 8. The date of the foreign adoption decree is


.

 9. The type of United States visa issued to the adopted child is:
(circle one)  IR-2, IR-3, IH-3, IR-4, IH-4

 10. The following documents are attached to this Petition:

 a. Copy of child’s birth certificate or other birth identification issued by country of birth; if none, an Affidavit of parent(s) stating why none is available.

 b. Copy of Decree of Adoption issued by foreign government; if Decree is not in English, an English translation certified by the translator to be correct.

 c. Copy of adopted child’s United States visa.

 d. Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed.

 e. Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency.

 f. A copy of U.S. Government Form N-560, Certificate of Citizenship, and/or a copy of the child’s United States passport, if either or both documents are available.

 WHEREFORE, Petitioner(s) request(s) that this Court enter a Decree authorizing the registration and docketing of the attached Foreign Adoption Decree with the Clerk of the appropriate Court and decreeing that





(Name of child as written on Foreign Adoption Decree)

shall henceforth be known as



(Child’s name from this time forward)

and shall have all the rights of a child and heir of the Petitioner(s).

          Signature of Adopting Parent*


         Signature of Adopting Parent

   



Daytime telephone no. for Adopting Parent(s)

*When there are two adopting parents, both must sign.

VERIFICATION TO PETITION TO REGISTER FOREIGN ADOPTION DECREE PURSUANT TO 23 Pa.C.S. §  2908

 I/We,


, verify that I/we am/are the Petitioner(s) named in the foregoing Petition, that I/we have read and understand the information set forth in the Instructions to the Petition to Register Foreign Adoption Decree, and that the facts set forth in the foregoing Petition are true and correct to the best of my/our knowledge, information and belief. I/We further verify that all documents attached to this Petition are true and correct copies of the originals. I/We understand that false statements made herein are subject to the penalties of 18 Pa.C.S. §  4904 relating to unsworn falsification to authorities.

 Date:





         Signature of Adopting Parent


         Signature of Adopting Parent

IN THE COURT OF COMMON PLEAS



COUNTY, PENNSYLVANIA


ORPHANS’ COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)


IN RE: FOREIGN ADOPTION OF


ADOPTION NO.


FINAL DECREE

 AND NOW, this


day of
, 20
, it is hereby ORDERED and DECREED that the Petition of
                 (Adopting Parent(s))
to Register Foreign Adoption Decree is GRANTED and that this Court authorizes the registration and docketing of the Foreign Adoption Decree entered on
by

 (Date of Foreign Decree)     (Name of Foreign Court)
in
.
   (Foreign Country)

 It is FURTHER ORDERED and DECREED that the above Foreign Adoption Decree shall be enforceable as if this Court had entered the Decree and that henceforth this child


shall be known as      (Name of child as written on
     Foreign Adoption Decree
)

and shall have all the rights of a child
(Child’s name from this time forward)
and heir of
.
       (Adopting Parent(s))

 BY THE COURT:     


J.


IN THE COURT OF COMMON PLEAS



COUNTY, PENNSYLVANIA


ORPHANS’ COURT DIVISION
(FAMILY COURT DIVISION in Philadelphia County)


IN RE: FOREIGN ADOPTION OF


ADOPTION NO.


FINAL DECREE

 AND NOW, this


day of
, 20
, it is hereby ORDERED and DECREED that the Petition of
                 (Adopting Parent(s))
to Register Foreign Adoption Decree is DENIED.

 BY THE COURT:     


J.


INSTRUCTIONS FOR FILING PETITION TO REGISTER FOREIGN ADOPTION DECREE PURSUANT TO 23 Pa.C.S. §  2908

 When a child is adopted in conformity with the laws of a foreign country, the adopting parent(s) may register the Foreign Adoption Decree so that the Decree is considered full and final, enforceable as if entered pursuant to the Pennsylvania Adoption Act, and a Pennsylvania birth certificate can be obtained.

 Adopting parent(s) seeking to register the Foreign Adoption Decree must:

 1. Complete, sign and date the Petition to Register Foreign Adoption Decree and Verification. If a Foreign Adoption Decree shows that there are two adopting parents, both parent(s) must execute the Petition to Register Foreign Adoption Decree.

 2. Attach the following documents to the Petition:

 • A copy of the Foreign Adoption Decree;

 • A copy of the child’s birth certificate. If no birth certificate was issued, a copy of any other birth identification issued by the country of birth should be attached. If no birth certificate or birth identification can be obtained, an Affidavit stating the reason should be submitted;

 • A copy of the child’s United States visa;

 • An English translation of all documents not in English, with a verification by the translator that all translations are true and correct;

 • Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed;

 • Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency;

 • If available, a copy of U.S. Government Form N-560 and/or a copy of the child’s U.S. passport.

 3. The Petition to Register with the attachments should be filed with the Clerk of the Orphans’ Court Division of the Court of Common Pleas in the county in which the adopting parent(s) reside(s), except for Philadelphia County resident(s), who must file with the Family Court Division. A filing fee will be charged in accordance with the fee schedule of the county court.

 After the Petition to Register is filed, it will be submitted to the Court for review. If the Petition to Register and accompanying documents establish that the foreign adoption of the child is full and final, the Court will enter a Decree directing the registration of the Foreign Adoption Decree. The Clerk of the appropriate Court will then issue a certificate of adoption and transmit to the Department of Health, Division of Vital Records Forms HD01273F and HD01275F, and if provided by the adopting parent(s), a copy of U.S. Government Form N-560 and/or a copy of the child’s United States passport.

 If the Court cannot determine that the foreign adoption is full and final, it will enter a Decree denying the Petition. In that case, it will be necessary to proceed under Pa.O.C. Rule 15.9.

 Some of the following are reasons why a foreign adoption may not be a full and final adoption eligible for registration:

 • both adopting parents were not present for the adoption hearing in the foreign country and the foreign country is not a Hague Convention country; or

 • the sole adopting parent was not present at the adoption hearing in the foreign country and the foreign country is not a Hague Convention country; or

 • the foreign court did not enter a final adoption Decree or Order or its equivalent; or

 • the child’s United States visa is not the type that affords the child full United States citizenship.

 If the child has an IH-4 or IR-4 United States visa, it will be necessary to proceed under Pa.O.C. Rule 15.9.

IN THE COURT OF COMMON PLEAS OF

COUNTY, PENNSYLVANIA
ORPHANS’ COURT DIVISION


(FAMILY COURT DIVISION in Philadelphia County)


IN RE: ADOPTION OF

            (initials only)


ADOPTION NO.


PRELIMINARY DECREE

 AND NOW, this


day of
, 20
, upon consideration of the within Petition and on the motion of
, Esquire, attorney for Petitioner(s) or
, Pro Se, a hearing thereon is fixed for
in
before the Honorable
at
am/pm.

 Notice shall be given to the following persons and or entities having any legal and/or physical rights to the child:

1.NAME
ADDRESS

RELATIONSHIP
2. NAME
ADDRESS

RELATIONSHIP
3. NAME
ADDRESS

RELATIONSHIP

 BY THE COURT:

 


J.


IN THE COURT OF COMMON PLEAS OF

COUNTY, PENNSYLVANIA
ORPHANS’ COURT DIVISION


(FAMILY COURT DIVISION in Philadelphia County)


IN RE: ADOPTION OF

            
(initials only)


ADOPTION NO.


FINAL DECREE

 AND NOW, this


day of
, 20
, upon consideration of the within Petition and after the hearing thereon, the Court having made an investigation to verify the statements of the Petition and other facts to give the Court full knowledge as to the desirability of the proposed adoption; and the Court, being satisfied, finds that the statements made in the Petition are true, that the needs and welfare of the child proposed to be adopted will be promoted by this adoption, and that all requirements of the Adoption Act have been met, it is hereby ORDERED, ADJUDGED and DECREED that this child,
is hereby adopted, shall be known

   (Name of child as written on Foreign Decree)

   as


and shall have all the rights of a child    (Child’s name from this time forward)
and heir of
,
              (Adopting Parent(s))
and shall be subject to the duties of a child to said adopting parent(s).

 BY THE COURT:

 


J.


IN THE COURT OF COMMON PLEAS OF



COUNTY, PENNSYLVANIA


ORPHANS’ COURT DIVISION


(FAMILY COURT DIVISION in Philadelphia County)


IN RE: ADOPTION OF

            (initials only)


ADOPTION NO.


PETITION FOR ADOPTION OF A FOREIGN BORN CHILD

 To the Honorable, the Judge of said Court:

 The Petition of



           (Name(s) of Adopting Parent(s))

 under 23 Pa. C.S. § §  2701 and 2908 respectfully states that:

 1. At least one of the Petitioners filing this Petition is a resident of the Commonwealth of Pennsylvania and has resided in this Commonwealth since


.
(Provide at least month and year)

 2. No other court in this Commonwealth or in any other state has reviewed, registered, finalized or otherwise assumed jurisdiction over the adoption of this child, except as follows:



            (Provide name of court, county and state)

 Explain the proceeding previously initiated and the resulting decision from the court: (Attach all court decrees).

 



 



 


 3. Petitioner(s) desire(s) to adopt this child known as

 


, and intend that such

    (Name of child as written on Foreign Decree)

 child shall be treated as one of (his/her/their) heirs and hereby declare(s) that (he/she/they) will perform all the duties of parent(s) to him/her.

 4. The child has entered the United States pursuant to a United States visa. A true and correct copy of the United States visa is attached as an exhibit to this Petition. The United States visa was issued as an:

 (Please circle one) IR-2, IR-3, IH-3, IR-4 or IH-4

 5. a) The child’s full name as shown on the United States visa is

 


 b) The full birth name of the child as listed on the foreign birth certificate (if available) is

 


 c) The full name of the child as it appears on the foreign decree is

 


 d) The full name of the child as he/she is to be known from this time forward is


 6. The child has resided with Petitioner(s) for the following length of time

 


 7. Information concerning the Petitioner(s), the adopting parent(s), is as follows:

 a) Adopting Father:

 1) Full name


 2) Residence


 


 3) Marital status


 4) Age


 5) Occupation


 6) Religious affiliation


 7) Racial background


 8) Relationship to adoptee by blood or marriage, if any


 9) Daytime telephone no.


 b) Adopting Mother:

 1) Full name


 2) Residence


 


 3) Marital status


 4) Age


 5) Occupation


 6) Religious affiliation


 7) Racial background


 8) Relationship to adoptee by blood or marriage, if any


 9) Daytime telephone no.


 8. The following reports, as applicable, have been completed as of the dates set forth below. A true and correct copy of each of these reports is attached as an exhibit to this Petition.

 a) Report of Intermediary described in 23 Pa.C.S. §  2533

 


 b) Home Study and/or Preplacement Reports described in 23 Pa.C.S. §  2530

 


 c) Investigation Reports described in 23 Pa.C.S. §  2535

 


 d) Postplacement Reports, if any

 


 9. Information concerning the intermediary agency, if any, is as follows:

 Name of agency


 Address



 



 


 Telephone no.


 County where office is located


 10. If there is no report of an intermediary, the following information is being provided by the Petitioner(s) as to the adoptee child:

 a) Sex


 b) Racial background


 c) Age


 d) Birth date


 e) Birthplace


 f) Places of residence since birth



 


 g) Religious affiliation


 h) A full statement of the value of all property owned or possessed by the child, if any



 



 


 i) State whether medical history information was obtained, and if not, explain why not



 



 


 11. If there is no report of an intermediary, and the adoptee child is under 18 years of age, provide the following information as to the birth mother, if known:

 a) Name


 b) Residence or last known address



 


 c) Racial background


 d) Age


 e) Marital status as of the time of the birth of child


 f) Marital status during one year prior to birth of child


 g) Religious affiliation


 h) Birth mother’s parental rights were terminated by decree of


dated

 12. If there is no report of an intermediary, and the adoptee child is under 18 years of age, provide the following information as to the birth father, if known:

 a) Name


 b) Residence or last known address



 


 c) Racial background


 d) Age


 e) Marital status as of the time of the birth of child


 f) Marital status during one year prior to birth of child


 g) Religious affiliation


 h) Birth father’s parental rights were terminated by decree of


dated

 13. If there is no report of an intermediary, attach a copy of the birth certificate. If no birth certificate or other birth identification issued by the country of birth can be obtained, a statement of the reason and a detailed explanation of the efforts made to obtain the certificate are required and attached as an exhibit to this Petition.

 14. If there is no report of an intermediary, attach copies of any foreign decrees and/or documents concerning this adoption, including any decree terminating the parental rights of birth mother and/or birth father, if needed, with an English translation for those decrees and/or documents not in English, certified by a translator to be true and correct translations of the foreign decrees and/or documents.

 15. If there is no report of an intermediary, attach all consents required by Section 2711 of the Adoption Code, 23 Pa.C.S. §  2711. If consents are not required, explain

 



 



 


 16. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and Part 3, if applicable) completed.

 17. Attach Pennsylvania Department of Health, Division of Vital Records Form No. HD01275F, Statement of Citizenship and Residency.

 18. Attach a copy of U.S. Government Form N-560, Certificate of Citizenship, and/or a copy of the child’s United States passport, if either or both documents are available.

 19. It is the desire of the Petitioner(s) that the relationship of parent and child be established between the Petitioner(s) and the adoptee child.

 WHEREFORE, Petitioner(s) pray your Honorable Court to enter a Final Decree that the child proposed to be adopted shall have all the rights of a child and heir of Petitioner(s) and Petitioner(s) shall be subject to the duties as parent(s) of such child, and that the child’s name shall henceforth be

 



 DATE:




Signature of Adopting Parent*


Signature of Adopting Parent

 


 


 


 


(If represented, counsel’s name, address,
and telephone number)

 * When there are two adopting parents, both must sign.

VERIFICATION TO PETITION FOR ADOPTION OF A FOREIGN BORN CHILD

 I/We,


, verify that I/we are the Petitioner(s) named in the foregoing Petition and that the facts set forth therein are true and correct to the best of my/our knowledge, information and belief. I/We further verify that all documents attached to this Petition are true and correct copies of the originals. I/We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §  4904 relating to unsworn falsification to authorities.

 DATE:




Signature of Adopting Parent


Signature of Adopting Parent

IN THE COURT OF COMMON PLEAS OF



COUNTY, PENNSYLVANIA



ORPHANS’ COURT DIVISION


(FAMILY COURT DIVISION in Philadelphia County)


IN RE: ADOPTION OF

            
(initials only)


ADOPTION NO.


REPORT OF THE INTERMEDIARY IN THE ADOPTION OF A FOREIGN BORN CHILD

 The report of the agency,


, as intermediary, under 23 Pa.C.S. §  2533, states as follows:

 1. Intermediary’s address



 



 


 Intermediary’s telephone no.


 County where office is located:


 2. The facts as to the adoptee child are:

 a) Name


 b) Sex


 c) Racial background


 d) Age


 e) Birth date


 f) Birthplace


 g) Religious affiliation


 3. Date of the placement of the child with the Petitioner(s), adopting parent(s),


 4. If known, the facts as to the birth mother are:

 a) Name


 b) Residence or last known address


 c) Racial background


 d) Age


 e) Marital status as of the time of the birth of the child

 


 f) Marital status during one year prior to birth of the child


 g) Religious affiliation


 h) Birth mother’s parental rights were terminated by decree of


dated

 5. If known, the facts as to the birth father are:

 a) Name


 b) Residence or last known address



 


 c) Racial background


 d) Age


 e) Marital status as of the time of the birth of the child


 


 f) Marital status during one year prior to birth of the child


 g) Religious affiliation


 h) Birth father’s parental rights were terminated by decree of


dated

 6. All consents required by 23 Pa. C.S. §  2711 are attached to this Report as exhibits or are not required for the following reasons, provide explanation:

 



 



 


 7. a) A true and correct copy of the birth certificate or a registration of the birth by the country of birth is attached to this Report as an exhibit. If no birth certificate or other birth identification issued by the country of birth can be obtained, a statement of the reason and a detailed explanation of the efforts made to obtain the certificate are attached as exhibits to this Report.

 b) Attach copies of any foreign decrees and/or documents concerning this adoption, including any decree terminating the parental rights of birth mother and/or birth father, with an English translation for those decrees and/or documents not in English, certified by a translator to be true and correct translations of the decrees and/or documents.

 8. Attach a verified list of itemized fees and/or expenses paid or to be paid to or received by the intermediary and/or any other person or persons to the knowledge of the intermediary by reason of the adoption placement.

 9. A full description and statement of the value of all property owned or possessed by the child, if any, is as follows:

 



 



 


 10. No provision of any act regulating the interstate placement of children has been violated with respect to the placement of the child.

 11. The child’s medical history information was obtained and is available, except as follows:



 



 



 DATE:


  

Signature
(Type name of signor, title, and name of agency)

VERIFICATION TO REPORT OF INTERMEDIARY

 I,


, verify that I am

 


of

 (Title)

 


 (Name of Agency)

 and I am authorized to take this verification on its behalf, and that the facts set forth in the foregoing Report are true and correct to the best of my knowledge, information and belief. I further verify that all documents attached to this Report are true and correct copies of the originals. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §  4904 relating to unsworn falsification to authorities.

 DATE:




Signature

VERIFICATION OF TRANSLATOR

 I,


, verify that I am a licensed translator and that all translations of the foreign documents which are attached to this Petition are true and correct English translations of the originals. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §  4904 relating to unsworn falsification to authorities.

 DATE:




Signature

   

IN THE COURT OF COMMON PLEAS

   

IN THE COURT OF COMMON PLEAS

   

IN THE COURT OF COMMON PLEAS

   

IN THE COURT OF COMMON PLEAS