Petition on adoption by Muskan at Lexcliq

The adoption petition and accompanying documents (adoption information sheet and vital records form) are NOT
served on the parties to the case. They are confidential pleadings and only are filed with the court. The adoption
judge’s orders in response to the filing of an adoption petition put the other parties on notice of the filing of the
adoption petition.
Ex Parte in the Matter of ) Adoption Case No. ________________
The Petition of )
[PETITIONER’S NAME] ) Judge/Magistrate Judge [NAME]
For Adoption of a Minor Child. )
The Petitioner, [PETITIONER] (“[PETITIONER]” or the “Petitioner”), represents to the
court as follows:
1. This Court has jurisdiction pursuant to D.C. Code § 16-301, et seq. (2009) in that the
prospective adoptee, [CHILD] (“[CHILD]”), is in the legal care, custody, or control of
the Child and Family Services Agency (“CFSA”). The Court’s jurisdiction also derives
from D.C. Code § 11-1101(9) (2011).
2. [PETITIONER] was born on [PETITIONER DOB] and is [AGE] years old. [HE/SHE] is
[RACE] and is a member of the [RELIGIOUS AFFILIATION] religion. [PETITIONER]
is self-employed as a [PROFESSION], and has been [PROFESSION] since [YEAR].
[HE/SHE] has never been married. [PETITIONER] resides at [ADDRESS]. [HE/SHE] owns this residence, which has five
bedrooms, and has lived there since [YEAR]. [PETITIONER]’s parents, [PARENT 1]
and [PARENT 2], and [PETITIONER]’s niece and her child, [NIECE] and [NIECE’S
CHILD] also reside at this address.
4. [CHILD] is a [AGE]-year-old boy, born on [DOB] in [CITY STATE]. [CHILD] is
[RACE] and [HIS/HER] religious affiliation is unknown.
5. [PETITIONER] is the licensed foster parent of [CHILD]. [CHILD] was placed in the
care of [PETITIONER] on [DATE] by the D.C. Child and Family Services Agency.
[HE/SHE] has lived with [PETITIONER] continuously since that time, which is over half
of [HIS/HER] life, and has thrived in [HIS/HER] care. [PETITIONER] and [CHILD]
enjoy a close and loving parent-child relationship.
6. [PETITIONER] is requesting an adoption subsidy. [CHILD] has special needs and has
been diagnosed as developmentally delayed. An adoption subsidy agreement has not
been entered into prior to the filing of this petition, but [PETITIONER] expects that one
will be entered into prior to finalization.
7. [PETITIONER] has not received the complete medical, social, or background
information on the prospective adoptee.
8. [CHILD]’s birth mother is [BIO MOM]. Her last known address is [ADDRESS]. [BIO
MOM] is [RACE]. Her religious affiliation is unknown.
9. On information and belief, [CHILD]’s putative birth father/father is [BIO DAD]. [BIO
DAD] is believed to be [RACE] and his religious affiliation is unknown. His address is
unknownbut it is anticipated the CFSA’s Dilligent Search Unit will attempt to locate him.
10. There are no executed original written consents signed by the birth mother or birth father.
Upon information and belief, there are no relinquishments of parental rights signed by the
birth parents. Upon information and belief there are no orders terminating parental rights
by a court of competent jurisdiction.
11. The name and address of the agency responsible for securing any required consent or
relinquishment of birth parents is the D.C. Child and Family Services Agency, 200 I
Street, SE, Washington, DC, 20003 [and PRIVATE AGENCY NAME/ADDRESS [if
12. The Interstate Compact on the Placement of Children (ICPC), D.C. Code § 4-1421 et
seq. (2009), is applicable to this adoption due to the fact that the Petitioner resides in
Maryland. Approval has not been received prior to the filing of this petition, but
Petitioner expects that ICPC approval will be obtained prior to finalization.
13. The Indian Child Welfare Act, 25 U.S.C. § 1901 et seq., is not applicable to this
14. [CHILD] is the subject of a neglect case, N-[###]-[##], before Judge/Magistrate Judge
[NAME]. [PETITIONER] is not aware of any other pending court action involving
15. In addition to the ongoing neglect case regarding [CHILD], N-[###]-[##], during the past
ten years, [PETITIONER] has been a party in the following civil matter:
a. [YEAR], [CASE NAME], Case No. [############] in the [COURT AND
16. Upon information and belief, [CHILD]’s combined assets do not exceed $3,000.00.
17. [CHILD] is physically, mentally, and otherwise suitable for adoption by [PETITIONER] 18. [PETITIONER] is fit and able to give [CHILD] a proper home and education.
19. [PETITIONER] desires to adopt and treat [CHILD] as [HIS/HER] natural child.
20. The adoption is in the best interest of [CHILD].
WHEREFORE, the Petitioner prays:
1. that a final decree of adoption be entered establishing the relationship of natural parent
and natural child for all purposes between the Petitioner, [PETITIONER], and the
prospective adoptee, [CHILD].
2. that the name of the prospective adoptee be changed to [CHILD’S NEW NAME].
3. that an order of reference with a copy of the Petition attached be served upon Child and
Family Services Agency for the purpose of verifying the allegations contained in the
Petition. A report is to be made to the Court within 90 days regarding the advisability of
the proposed adoption.
4. that the the consent of the biological parents is not required pursuant to D.C. Code § 16-
5. For such other and further relief as may seem just and proper to the Court.
Date Signature of Petitioner
[PETITIONER] , being first sworn, states that [HE/SHE] has read the Petition
for Adoption and understands its terms and that the statements contained in this Petition are true to the
best of [HIS/HER] information and belief. _______________________________
Subscribed and sworn to before me this ______ day of [MONTH YEAR].
Deputy Clerk/ Notary Public
D.C. Bar No. ######
Counsel for [PETITIONER]
The following information is needed for the purpose of locating the original record of birth in
the office files.
1. Original name of child [CHILD]
2. Date of birth [CHILD DOB] Place of birth [CITY STATE]
3. Name of putative natural father [BIO DAD]
4. Name of natural mother (including maiden name) [BIO MOM]
5. Birth certificate number if known
6. Name of child-placing agency
(required only when the names of the natural parents are
In order that there may be a complete record of the history of the adoptive parents as if they
were the natural parents on the new certificate, it will be necessary that the information
requested below be furnished.
Full name [PETITIONER]__
Race [RACE] Age [AGE]
Birthplace [CITY, STATE]
Occupation [OCCUPATION]
Usual residence [ADDRESS]
Other children born to, or adopted by this mother (Do not include this child):
No. now living # No. born alive but now dead # No. born dead #
The items regarding the age, occupation, and residence of the adoptor is to be furnished as
of the date that the adoptee was born.

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