In the interest of




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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY

For Official Use



IN THE INTEREST OF


     

a person under the age of 18.





Petition for
Adoptive Placement


     

Date of Birth


Case No.      




Under oath, I state that:


1.  a. The child was born on the date indicated above and resides at:      

 b. The child is due to be born about       .
2. The birth mother       , age       ,

resides at       .


3. The birth father       , age       ,

resides at       .


4. The proposed adoptive mother       , age       ,

resides at       .


5. The proposed adoptive father       , age       ,

resides at       .


6. (Person/agency)       arranged placement of the child.


  1. The report of financial, medical and legal arrangements is attached.




  1. The placement is in a licensed foster home.




  1. The Petition for Termination of Parental Rights accompanies this petition.

10.  a. The child is not subject to the federal Indian Child Welfare Act.

 b. The child is subject to the federal Indian Child Welfare Act, and:

1. Indian tribe’s name and address:      

2. Indian custodian’s name and address: (if applicable)      

3.  Placement has been made in accordance with the order of preference set forth in the Indian Child Welfare Act.



OR

 There is good cause to depart from the order of placement preference in the Indian Child Welfare Act:      




Subscribed and sworn to before me

on      


Notary Public, State of Wisconsin

My commission expires:      



Petitioner



     

Name Printed or Typed



Petitioner



     

Name Printed or Typed



     

Date

Distribution:

1. Court-Original

2. Parties

3. Tribe (if any)






JC-1640, 04/09 Petition for Adoptive Placement §48.837, Wisconsin Statutes; 25 U.S.C. §1915.

This form shall not be modified. It may be supplemented with additional material.


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