Petition For Adoption Form

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STATE OF MINNESOTA
DISTRICT COURT
COUNTY OF DAKOTA
FIRST JUDICIAL DISTRICT
FAMILY DIVISION
IN THE MATTER OF THE PETITION OF
PETITION FOR ADOPTION
__________________________________________ and
_______________________________________ his wife
Court File No.:
to adopt ______________________________________
D.H.S. No.:
(name known to petitioners)
YOUR PETITIONERS Respectfully Requests and Shows to the Court:
1. That they are husband and wife, and were married at _______________________________________ County of
___________________________________, State of ______________________________________, on the
________________ day of _________________________, _____________, that their full names and ages are:
_________________________________ age _______________ and ________________________________ age
____________ that they reside at _________________________________________________________ City of
__________________________ County of __________________________, State of Minnesota; and for more
than one year immediately preceding the filing of this petition.
2. That a ______male child was placed in their home for adoption on _________________________________, by
______________________________________________ a child placing agency duly licensed by the State of
Minnesota; and that said child has been in their home and custody since said date. (or) That the Human Services
Department of _____________________________ County, as agent for the Commissioner of Human Services,
State of Minnesota, placed a ______male child in the home of petitioners on ___________________________,
and that said child has been in their home and under their custody ever since. (*)
3. That the petitioners, on information and belief, state that said child has no interests in real estate, personal property
or trust fund agreements, at this date: (**) _________________________________________________________.
4. That on information, Petitioners state that the name of said child is (***) ________________________________
(or) unknown, and was born in the County of ________________________, State of _______________________,
on the ____________ day of ____________________________, ________, and that your petitioners desire that its
name be changed to ___________________________________________________________________________.
5. That your petitioners have been informed by the placement agency, that all of the pertinent and required
information under the Statutes concerning said child herein so placed for adoption, and the natural parents thereto,
birthdate and place, is recorded in the placements agencies; Case No.__________________________, and/or, in
the files of the Commissioner of Human Services, State of Minnesota, in case No. ________________________.
That said placement agency has consented to this adoption.
6. That on information and belief of petitioners, the Commissioner of Human Services, or other appropriate agency,
upon receipt of a copy of this petition, together with the required Notice, will, pursuant to M.S.A. Section 259.27,
as amended, transmit to the Court, all required records, reports, and recommendation, together with consent and
legal documents, as required under M.S.A. Sections 259.21 to 259.32 inclusive.

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