Free AGENCY PLACEMENT PETITION.PDF - Minnesota

STATE OF MINNESOTA COUNTY OF DAKOTA

DISTRICT COURT FIRST JUDICIAL DISTRICT FAMILY DIVISION

IN THE MATTER OF THE PETITION OF

PETITION FOR ADOPTION
__________________________________________ and _______________________________________ his wife to adopt ______________________________________
(name known to petitioners)

Court File No.: D.H.S. No.:

YOUR PETITIONERS Respectfully Requests and Shows to the Court:
1. That they are husband and wife, and were married at _______________________________________ County of ___________________________________, State of ______________________________________, on the ________________ day of _________________________, _____________, that their full names and ages are: _________________________________ age _______________ and ________________________________ age ____________ that they reside at _________________________________________________________ City of __________________________ County of __________________________, State of Minnesota; and for more than one year immediately preceding the filing of this petition. 2. That a ______male child was placed in their home for adoption on _________________________________, by ______________________________________________ a child placing agency duly licensed by the State of Minnesota; and that said child has been in their home and custody since said date. (or) That the Human Services Department of _____________________________ County, as agent for the Commissioner of Human Services, State of Minnesota, placed a ______male child in the home of petitioners on ___________________________, and that said child has been in their home and under their custody ever since. (*) 3. That the petitioners, on information and belief, state that said child has no interests in real estate, personal property or trust fund agreements, at this date: (**) _________________________________________________________. 4. That on information, Petitioners state that the name of said child is (***) ________________________________ (or) unknown, and was born in the County of ________________________, State of _______________________, on the ____________ day of ____________________________, ________, and that your petitioners desire that its name be changed to ___________________________________________________________________________. 5. That your petitioners have been informed by the placement agency, that all of the pertinent and required information under the Statutes concerning said child herein so placed for adoption, and the natural parents thereto, birthdate and place, is recorded in the placements agencies; Case No.__________________________, and/or, in the files of the Commissioner of Human Services, State of Minnesota, in case No. ________________________. That said placement agency has consented to this adoption. 6. That on information and belief of petitioners, the Commissioner of Human Services, or other appropriate agency, upon receipt of a copy of this petition, together with the required Notice, will, pursuant to M.S.A. Section 259.27, as amended, transmit to the Court, all required records, reports, and recommendation, together with consent and legal documents, as required under M.S.A. Sections 259.21 to 259.32 inclusive.

7. That the petitioners desire that the relationship of parent and child be established between the petitioners and the child herein, and that it is for the best interest of said child that it be adopted by said petitioners. WHEREFORE, Your Petitioners pray for an order directing the entry of a decree for adoption of said child by petitioner in accordance with the Statutes in such cases made and provided and that the name of the child be changed to ____________________________________________________________ and for such other orders as the Court may deem advisable. Dated:________________________________

_____________________________________ _____________________________________ Attorney and Address

_______________________________________ Petitioner _______________________________________ Petitioner

STATE OF MINNESOTA

) )ss COUNTY OF __________________)

VERIFICATION

_________________________________________ and _____________________________________ his wife, being first duly sworn on oath state that they have read the foregoing petition subscribed by them, and that they know the contents thereof, and that the same is true to their best information and belief.

Subscribed and sworn to before me this _________ Day of ________________________, 20________. _________________________________________ Notary Public, ______________________ County State of Minnesota My Commission expires________________________

______________________________________ Petitioner ______________________________________ Petitioner

Note:

*#2. Is for private agency or Department-strike one not pertinent. **#3. If child has property add "Excepting as stated on Exhibit `A' attached. ***#4. Name may be "Baby Boy `Jones'" or "unknown" or full name may be known-use proper fact.