Free PC-680 - Connecticut

ADOPTION DATA SHEET PC-680 REV. 3/05

STATE OF CONNECTICUT

RECORDED (CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink. ] [ File with all applications for approval of adoption agreements.] [Attach following documents as exhibits: certified copy of Birth Certificate of Minor Child, Record of Adoption (Public Health Form VS-51) where required.] TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF A MINOR CHILD BORN ON Proposed Name of Minor Child after Adoption Given Name as Shown on Birth Certificate Place of Birth Presently Residing at [Street, town, state, and zip code]
.

DISTRICT NO.

Genetic Mother [Full name and last known address]

Genetic Father [Full name and last known address. Include putative father. C.G.S. §§ 45a-716(b), 45a-604(2)]

If deceased, give date and place of death:

Mother:

Father:

Divorced: [Date of decree and court where granted] Parent(s) whose parental rights have been terminated: Mother: Court Mother: Date Statutory Parent [Name and address of main or local office] Father: Court Father: Date Guardian of the Person [If not genetic parent. Except in a stepparent or co-parent adoption, a guardian may give in adoption only to a blood relative. C.G.S. §45a-724(a)(3)].

Date of Appointment: Court of Appointment: Adopting Parent [Full name, address, zip code, tel. no., and relationship to child] Court of Appointment:

Date of Appointment:

Adopting Parent [Full name, address, zip code, tel. no., and relationship to child]

Date and place of marriage, if applicable THE SUBSCRIBER REPRESENTS that, to his or her best knowledge and belief, there is no other proceeding pending or contemplated in any other court affecting the custody of the minor child to be adopted, OR if there is such a proceeding, a statement is attached explaining in detail the nature of the proceeding and averring that the proposed adoption will not conflict with or interfere with such other proceeding. C.G.S. §§45a-727, 52-231a. The foregoing data submitted in connection with the application for approval of the Adoption Agreement concerning said minor child is true to my best knowledge and belief. The representations contained herein are made under the penalties of false statement.

Date:

Subscriber ........................................................................................ Print Name: Address:

ADOPTION DATA SHEET PC-680

RESET