ADOPT-200 Adoption Request

d.
e.
Your name:
Case Number:
I/We will ask the court to end the parental rights of (attach copy of Petition to Terminate Parental Rights or
Application for Freedom From Parental Custody, if filed):
Relationship to child:Name:
Relationship to child:Name:
Adopting parent has custody of the child by court order or by agreement with the other parent, and each of
the following persons with parental rights has not contacted the child and has not paid for the child’s care,
support, and education for one year or more when able to do so. (Fam. Code, § 8604(b).)
Relationship to child:Name:
Relationship to child:Name:
Relationship to child:Name:
ADOPT-200, Page 4 of 5
Adoption Request
b.
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
(Enter the date of the court order ending parental rights and attach a copy of the order.)
c.
(Attach a copy of the order.)
A court ended the parental rights of:
The child is the subject of a tribal customary adoption order under Welfare and Institutions Code section
366.24, which has modified the parental rights of:
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
Relationship to child:
on (date):
Name:
(1)
f.
(2)
The child has been abandoned as follows:
The child has been left by the child’s parent or parents with no way to identify the child.
The child has been left in the custody of another person by both parents or the sole parent for six
months without providing for the child’s support, or without communication from the parent or
parents, with the intent to abandon the child.
(3)
(If any of the above boxes were checked, adopting parent must also check item 15(d) and file
an Application for Freedom from Parental Custody. See Fam. Code, § 7822(a).)
h.
g.
One parent has left the child in the care and custody of the other parent for one year or longer
without providing for the child’s support or without communication from the parent, with the intent
to abandon the child.
The consent of the presumed father is not required because he did not become a presumed father before the
mother’s relinquishment or consent became irrevocable or the mother’s parental rights were terminated.
(Fam. Code, § 8604(a).)
Each of the following persons with parental rights has died:
Relationship to child:Name:
Relationship to child:Name:
Revised January 1, 2014
Page 4/5
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ADOPT-200 Adoption Request PDF

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