Free PC-604 - Connecticut

APPLICATION/VALIDATION OF FOREIGN ADOPTION PC-604 REV. 10/06

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] [Attach authenticated and exemplified copy of adoption.]

RECORDED(CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF

DISTRICT NO. DATE AND PLACE OF BIRTH OF MINOR CHILD

Hereinafter referred to as the minor child. PETITIONER [Name, address, zip code, and telephone number] C.G.S. §45a-730 Adoptive Parent Child-placing Agency

PARENT(S)[Name(s), address, zip code, and telephone number(s)] Mother:

Father:

Mother's Maiden Name: THE PETITIONER REPRESENTS that: The petitioner resides in this probate district, or the main or a local office of the statutory parent, if any, is located in this district. An authenticated and exemplified copy of adoption is submitted with this application and made a part hereof, and the factual information in this document and the data herein provided are true and complete to the best knowledge and belief of the petitioner. An authenticated and exemplified copy of adoption is not submitted with this application. [Please explain.]

To the best knowledge and belief of the petitioner, there is a no proceeding pending or contemplated in another court affecting the custody of said minor child. C.G.S. §45a-727. [If such a proceeding is pending or contemplated, give full details on Second Sheet, PC-180.] The adoption of the minor child who was born outside the United States or its territories occurred outside the United States or its territories. United States Immigration and Naturalization Services refuses to naturalize said minor because the adoptive parents did not personally see and observe the child prior to or during the adoption proceedings. WHEREFORE,THE PETITIONER REQUESTS that this Court: Validate the adoption of the aforesaid minor child.

The representations contained herein are made under the penalties of false statement.

Date:

............................................................................... Petitioner:

APPLICATION/VALIDATION OF FOREIGN ADOPTION PC-604

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