Rcpc Form A-1 Application For Placement For Adoption
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1
2PROBATE COURT OF RICHLAND COUNTY, OHIO
PLACEMENT OF
(Name before placement)
CASE NO.
APPLICATION FOR PLACEMENT FOR ADOPTION
R.C. 5103.16 (D)
[Check all boxes which apply]
Now come(s)
and
and say(s):
Applicant(s) is/are
[ ]
mother and father of child to be placed for adoption and we are
and
years of age, respectively.
[ ]
mother and sole parent of child to be placed for adoption and mother
is
years of age.
[ ]
father and sole parent of child to be placed for adoption and father
is
years of age.
The marital status of
[ ]
the mother is
and if divorced, the date, court
name and case number is
and if
married, the date of the marriage is
and name of her
spouse is
.
The child to be placed for adoption
[ ]
was born on
.
[ ]
is not yet born at the time of application and the anticipated date
of delivery is
.
The Identity of the prospective adoptive parent(s) is/are
[ ]
known by birth parent(s)
[ ]
unknown by birth parent(s)
[ ]
requested not to be revealed to the birth parents.
[ ] Birth parent(s) have been informed that the birth parent(s) and
prospective adoptive parent(s) may enter into a nonbinding open adoption
in accordance with Section 3107.63 of the Revised Cod.
[ ] Applicant(s) have or will place the child in the temporary custody of the
prospective adoptive parent(s), one or both of whom are related by blood
or marriage to one or both applicants.
[ ] Applicant(s) request that the Court place the child in the temporary
custody of the prospective adoptive parent(s) who are nonrelated to
applicant(s).
An affidavit (RCPC Form A-2) regarding biological father
[ ]
is attached
[ ]
is unnecessary as biological father has consented to the placement.
[ ] Attached hereto is a certified copy of the birth certificate or statement
why it is not available.
RCPC FORM A-1 APPLICATION FOR PLACEMENT FOR ADOPTION
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