Affidavit Of Petitioner For Adoption - Plymouth County Registry Of Probate
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1Commonwealth 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
FATHER
(PRINT name of petitioner including maiden name)
(PRINT name of petitioner)
(street address)
(street address)
City or town/state/zip code)
City or town/state/zip code)
(telephone number)
(telephone number)
(date of birth)
(date of birth)
(place of birth: city/town, state, county, country)
(place of birth: city/town, state, county, country)
(occupation at the time of adoption)
(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
The above signed made oath before me on
__________________________________________
__________________________________________
(date)
(date)
that this affidavit is her free act and deed.
that this affidavit is her free act and deed.
Notary Public________________________________
Notary Public________________________________
Print Name _________________________________
Print Name _________________________________
My Commission Expires: _______________________
My Commission Expires: _______________________
Affidavit of Petitioner for Adoption CJ-P 96
c.g.f.
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