Free Affidavit of Petitioner for Adoption - Massachusetts

Commonwealth of Massachusetts The Trial Court Probate and Family Court Department
Division Docket No.

Affidavit of Petitioner for Adoption M.G.L. c. 21 0, § 6
MOTHER
(PRINT name of petitioner including maiden name) (street address)

FATHER
(PRINT name of petitioner) (street address)

City or town/state/zip code) (telephone number) (date of birth) (place of birth: city/town, state, county, country) (occupation at the time of adoption)

City or town/state/zip code) (telephone number) (date of birth) (place of birth: city/town, state, county, country) (occupation at the time of adoption)

I (We) hereby request that a certificate of this adoption be sent to the city or town clerk of the place of birth of the child and that the clerk of the records amend the birth certificate of the child to reflect this adoption.

SIGNATURE OF MOTHER

SIGNATURE OF FATHER

NOTARIZATION

The above signed made oath before me on __________________________________________
(date)

The above signed made oath before me on __________________________________________
(date)

that this affidavit is her free act and deed. Notary Public________________________________ Print Name _________________________________ My Commission Expires: _______________________

that this affidavit is her free act and deed. Notary Public________________________________ Print Name _________________________________ My Commission Expires: _______________________

Affidavit of Petitioner for Adoption CJ-P 96

c.g.f.