ADOPT-200 Adoption Request

Case Number:
Your name:
ADOPT-200, Page 5 of 5
Adoption Request
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Revised January 1, 2014
17
for the following reason (Fam. Code, § 8601.5):
(Enter a date no earlier than the date parental rights were ended.)
I/We ask the court to approve the adoption and to declare that the adopting parents and the child have the legal
relationship of parent and child, with all the rights and duties of this relationship, including the right of
inheritance.
I/We ask the court to date its order approving the adoption as of an earlier date
(date):
Suitability for adoption
Each adopting parent:
Will support and care for the child;
Has a suitable home for the child; and
Agrees to adopt the child.
Is at least 10 years older than the child or
meets the criteria in Family Code section
8601(b);
Will treat the child as his or her own;
a.
b.
c.
d.
e.
This is a tribal customary adoption. I/We ask the court to approve the adoption and to declare that the adopting
parents and the child have the legal relationship of parent and child, with all of the rights and duties stated in the
attached tribal customary adoption order and in accordance with Welfare and Institutions Code section 366.24.
If a lawyer is representing you in this case, he or she must sign here:
18
Date:
Type or print your name
Signature of attorney for adopting parent(s)
I declare under penalty of perjury under the laws of the State of California that the information in this form and all
its attachments is true and correct to my knowledge. This means that if I lie on this form, I am guilty of a crime.
Signature of adopting parent
19
Date:
Type or print your name
Signature of adopting parent
Date:
Type or print your name
16
NOTICE—ACCESS TO AFFORDABLE HEALTH INSURANCE: Do you or someone in your household need affordable health
insurance? If so, you should apply for Covered California. Covered California can help reduce the cost you pay toward high-quality
affordable health care. For more information, visit www.coveredca.com. Or call Covered California at 1-800-300-1506 (English) or
1-800-300-0213 (Spanish).
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