Free Waiver of Right to Counsel and Request to Represent Youself (Pro Se) - New Hampshire

Instructions

Clear Form

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

In the adoption of

PETITION FOR ADOPTION OF AN ADULT
(RSA 170-B) A CERTIFIED COPY (LONG FORM) OF THE ADOPTEE'S BIRTH CERTIFICATE AND ASSENTS MUST BE FILED WITH THIS PETITION. 1. Petitioner Name Petitioner Name Mailing Address Residence How long has petitioner(s) been resident(s) of this city/town? 2. Attorney Name Mailing Address 3. Marital status of petitioner(s): Married Civil Union Single Telephone Bar ID # Other Telephone Date of Birth Date of Birth

If married or civil union, date and place of ceremony 4. 5. Petitioner(s) relationship to adoptee Adoptee Birth Name Place of Birth Residence Address 6. Birth Mother Name Mailing address 7. Birth Father Name Mailing address The petitioners declare that it is the desire of the petitioners to establish the relationship of parent and child with the adoptee. Therefore, the petitioners ask that this adoption be decreed and that the name of the adoptee be as follows: (Check all appropriate boxes. See Instructions for more information.) Change the name on the adoptee's birth certificate to The adoptee's legal name will be
Date Date
NHJB-2519-P (06/04/2008)

Date of Birth

Telephone

Telephone

Petitioner Signature (Must be signed in presence of notarial officer.) Petitioner Signature (Must be signed in presence of notarial officer.)
Page 1 of 2

Top of Page

Case Name: In the adoption of Case Number: PETITION FOR ADOPTION

State of This instrument was acknowledged before me on

, County of by
Date Petitioner Name

My Commission Expires Affix Seal, if any

Signature of Notarial Officer / Title

ASSENTS ADOPTEE'S ASSENT
I am the adoptee mentioned in this petition. I give my assent to the adoption and the change of my name as described in this form.
Date Adoptee's Signature Presiding Judge

Signed in the presence of

ASSENT OF PETITIONER'S SPOUSE WHO IS PARENT OF ADOPTEE
I am the spouse of the petitioner and parent of the adoptee, and will maintain all those parental rights along with the petitioner. I give my assent to the petitioner's adoption of the adoptee named in this petition and to the change of the adoptee's name as described in this petition.
Date Parent Signature

ASSENT OF PETITIONER'S SPOUSE TO ADOPTION OF ADULT
I am the spouse of the petitioner, and assent to the petitioner's adoption of the adoptee named in this petition.
Date Spouse Signature

ASSENT OF ADOPTEE'S SPOUSE
I am the spouse of the adoptee, and I assent to this adoption.
Date Spouse Signature

DECREE
Petition for adoption is granted. Petition for adoption is denied.
Date Judge

NHJB-2519-P (06/04/2008)

Page 2 of 2

Top of 1st Page