COURT .............. ........... .......... ADOPT-200 . . .Adoption .Request . . . . . . . . . . . . . . .: COUNTY OF
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If you are adopting more than one child, fill out an adoption request for each child.
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: Plaintiff(s) Your name(s) (adopting parent(s)): -against: a. b. : Relationship to child: Your address: : Street: Defendant(s) : City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . .Zip: . . . . . . . . . . ..... ...
Court name and street address:
Superior Court of California, County of
Your phone #:( ) Your lawyer (if you have one): (Name, address, phone #, and State Bar #): THE PEOPLE OF THE STATE OF NEW YORK
TO
Case Number:
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Type of adoption: (Check one) GREETINGS:(name): Agency Relative WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Independent , the Honorable at the Court International (name of agency): at located County of Stepparent/Domestic Partner of in room , on the day , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 3 Information about the child: a. The child’s new name will be: e. Place of birth (if known): City: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to b. Boy Girl Country: State: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a c. Date of failure f. If the child is 12 or older, does the child agree to result of yourbirth: to comply. Age: the adoption? Yes No d. Child’s address (if different from yours): Zip: Street: City: Witness, Honorable , one of theState: of the Justices Court in County, day of , 20 Child’s name before adoption (Fill out ONLY if this 4 is an independent, relative, or stepparent/domestic (To be completed by the clerk of the superior court partner adoption.): if a hearing date is available.)
(Attorney must sign above and type name below)
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Does the child have a legal guardian? Yes No If yes, attach a copy of the Letters of Guardianship and fill out below: a. Date guardianship ordered: b. County: c. Case number: Is the child a dependent of the court? If yes, fill out below: Juvenile case number: County: Yes No
Hearing is set for: Hearing Datel Attorney(s) for Date: Time:
Dept.: Room: Name and address of court if different from above:
Office and P.O. Address
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To the person served with this request: If you do not come to this hearing, the judge can order the adoption without your input.
Judicial Council of California, www.courtinfo.ca.gov Rev. January 1, 2004, Mandatory Form Family Code, §§ 8714, 8714.5, 8802, 8912, 9000; Welfare & Institutions Code, § 16119; Cal. Rules of Court, rule 1464
Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Adoption Request
ADOPT-200, Page 1 of 3
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Case Number:
Your name(s): 7 8 Child may have Indian ancestry: Yes No If yes, attach Form ADOPT-220, Adoption of Indian Child. If this is an Agency Adoption: a. I/We have received information about the Adoption Assistance Program, Regional Center, and mental health services available through Medi-Cal or other programs. No Yes b. All persons with parental rights agree the child should be placed for adoption by the California Department of Social Services or a licensed adoption agency (Fam. Code, § 8700) and have signed a Relinquishment form approved by the California Department of Social Services except: Name: Name: 9 If this is an Independent Adoption: a. A copy of the Adoptive Placement Agreement is attached. (Required in most independent adoptions; see Fam. Code, § 8802.) b. I/We will file promptly with the department or delegated county adoption agency information required by the department in the investigation of the proposed adoption. Yes No c. All persons with parental rights agree to the adoption and have signed the Adoptive Placement Agreement Consent to Adoption on a form approved by the California Department of Social Services except: Name: Name: 10 Relationship to child: Relationship to child: Relationship to child: Relationship to child:
If this is a Stepparent/Domestic Partner Adoption: in state out of state a. The birth parent is (If out of state and unable to sign in the presence of the required official, the parent may sign his or her consent before a notary. (Fam. Code, § 9003 (b).)) (date). b. Adopting parents married: (date) OR Domestic partnership registered: (This does not affect the social worker’s recommendation. Information is for court only. There is no waiting period.)
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There is no presumed or biological father because the child was conceived by artificial insemination using semen provided to a medical doctor or a sperm bank. (Fam. Code, § 7613.) Form ADOPT-310, Contact After Adoption Agreement: Is attached Will not be used Undecided at this time Will be filed at least 30 days before the adoption hearing
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Name of birth parents if you know: a. b. The consent of the § 8606 subdivision): birth mother
(mother) (father) presumed father is not necessary because (specify Fam. Code,
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Rev. January 1, 2004
Adoption Request
ADOPT-200, Page 2 of 3
Case Number:
Your name(s): 15 A court ended the parental rights of: Name: Name:
Relationship to child: Relationship to child:
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I/We will ask the court to end the parental rights of: Name: Name: Relationship to child: Relationship to child:
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Each of the following persons with parental rights has not contacted his or her child in one year (Fam. Code, § 8604(b)): Name: Name: Relationship to child: Relationship to child:
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Each of the following persons with parental rights has died: Name: Name: Relationship to child: Relationship to child:
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Suitability for Adoption: Each adopting parent: a. Is at least 10 years older than the child b. Will treat the child as his or her own c. Will support and care for the child d. Has a suitable home for the child and e. Agrees to adopt the child.
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I/We ask the court to approve the adoption and to declare that the adopting parent(s) 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. If a lawyer is representing you in this case, he or she must sign here: Date:
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Type or print your name
Signature of Attorney for Adopting Parent
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I declare under penalty of perjury under the laws of the State of California that the information in this form is true and correct to my knowledge. This means 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
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Rev. January 1, 2004
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ADOPT-200, Page 3 of 3
Adoption Request