Free Birth Parent Petition - Wyoming

WYCAI-2 (REV. 12/05/07)

STATE OF WYOMING

) ) COUNTY OF ________________________) IN THE MATTER OF THE ADOPTION OF

IN THE DISTRICT COURT SS ______________ JUDICIAL DISTRICT CASE # __________________________ BIRTH PARENT'S AFFIDAVIT AND PETITION TO APPOINT A CONFIDENTIAL INTERMEDIARY PURSUANT TO W.S. 1-22-203(b)

) ) ) ) ) _______________________________________)

_____________________________________________, being first duly sworn, on oath, petitions and says: (name of petitioner) My telephone numbers are: (home) ____________________________(work) _______________________ (cell) _______________________________. E-mail address_____________________________________ Mailing address_________________________________________________________________________. My birth son/daughter was born in _________________________________________________on (city/county) __________________________________________ and is 18 years of age or older. (date of birth) Date of relinquishment:____________________City/County______________________________ Birth parents' names at the time of relinquishment: ______________________________________ The adoption was finalized in ________________________________________Unknown _______ (City/County) The name of my birth son/daughter at time of birth: _____________________________________ Adoptive parents' names, if known: __________________________________________________ I know the following about my birth son's/daughter's adoptive family:_______________________ ______________________________________________________________________________________ ______________________________________________________________________________________ I am seeking my birth son/daughter because: ___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ I, therefore, petition this court and respectfully request that an order be entered appointing a confidential intermediary, pursuant to W.S. 1-22-203(b) and that the confidential intermediary be allowed to inspect and copy, at the petitioner's expense, the pertinent adoption files of the court, governmental agencies, adoption agencies and hospitals. DATED this ________________day of ___________________________________________, 20 _______. _____________________________________________ (Petitioner's signature) SUBSCRIBED AND SWORN to before me this ___________ day of __________________, 20________. My commission expires: ___________________________________ _____________________________________________ NOTARY PUBLIC OR DEPUTY CLERK OF COURT