WAIVER OF NOTICE AND CONSENT BY BIOLOGICAL...

© 2014 All Rights Reserved 2014 Supp. App. 5-1

Supplemental Form A

WAIVER OF NOTICE AND CONSENT BY BIOLOGICAL MOTHER

FOR ADOPTION OF HER MINOR CHILD

I, _(biological mother’s name)_ an adult, being first duly sworn upon my oath, state under the

penalties for perjury that:

1. I am the biological mother of a _(child’s gender)_, named _(child’s name)_ (hereinafter

the Child), born on _(child’s birthday)_, at _(time of birth, a.m./p.m.)_, in _(location of birth)_.

2. I am not an enrolled member of an Indian tribe nor of an Alaskan Village and, to the

best of my knowledge, I am not eligible for membership in an Indian tribe or an Alaskan

Village.

OR (option)

2. I am a member of or eligible for membership in an Indian tribe or an Alaskan Village.

The name of the tribe of which I am a member or eligible for membership is ______________.

The name of my ancestor with Indian heritage is __________________. The ancestor’s blood

relationship to me is ___________________ and the ancestor’s date of birth is

______________. The tribal registration number is _______________________.

3. The Child was conceived in the State of Indiana.

4. The Child was born out of wedlock. I have not been married within three hundred

(300) days prior to the birth of the Child. I choose not to identify the putative father of the

child. I did not sign a paternity affidavit, and the father’s name is not on the birth certificate.

5. Paternity of the Child has not been established in a court proceeding. To the best of my

knowledge, no paternity action has been initiated.

6. I believe the adoption of the Child would be in the best interests of the Child.


7. I hereby consent to the Child now being given into the care, custody, and control of

_(adoptive parents’ names)_ (hereinafter the adoptive parents), both of whom have promised to

give the Child a loving and secure home. I also voluntarily agree that a petitioner for adoption

may be substituted without my additional consent. I hereby authorize the adoptive parents, or

either one of them individually, to file adoption proceedings for the Child in the court of

appropriate jurisdiction. I hereby consent to the adoption of the Child by the adoptive parents,

including any substituted adoptive parent(s) without my additional consent.

I SPECIFICALLY WAIVE ANY AND ALL FURTHER NOTICE of the proceedings.

8. I consent to custody of the Child be given to the adoptive parents, including any

substituted adoptive parent(s), pending a hearing by the court on adoption.

9. I understand the signing of this consent to the adoption will result in a complete

termination of my parental rights upon the entry of a final decree of adoption; and when the

Court so decrees, the Child shall be and become a child of the adoptive parents.

10. I am not under the influence of any alcohol or drugs at the time of the signing of this

consent to adoption. I have not received, nor have I been promised, any money from the

adoptive parents or any party on their behalf either directly or indirectly. I have not been

threatened or intimidated into signing this consent. My rights have been explained to me, and I

am fully aware of the consequences of my signing of this consent to adoption.

11. I have had enough time to carefully consider whether or not adoption is in my own best

interest and the best interests of the Child. I have given my decision to proceed with this

adoption careful thought.

12. I am ____ years of age. I am of sound mind and body. I am fully aware of all

implications of this consent, and I know that I cannot withdraw my consent.


13. I understand that _(attorney’s name)_ represents the prospective adoptive parents and

does not represent me. I have chosen not to be represented by an attorney.

14. I submit to the jurisdiction of the Courts of the State of Indiana and acknowledge and

agree that all matters relating to the adoption of the Child, including, but not limited to, the

revocability or irrevocability of this consent to adoption, shall be determined in accordance

with the laws of the State of Indiana.

15. I UNDERSTAND THAT THIS CONSENT TO ADOPTION IS FINAL AND

LEGALLY BINDING.

DATED: _________ _____________________________________

Biological Mother

STATE OF INDIANA )

) SS:

COUNTY OF MARION )

BEFORE ME, a Notary Public in and for said County and State, personally appeared

_(biological mother’s name)_, and, being first duly sworn upon her oath, acknowledged the

execution of the foregoing Waiver of Notice and Consent by Biological Mother to Adoption of

Her Minor Child, and stated that the facts and matters therein set forth are true and correct.

WITNESS my hand and seal, this ________ day of _________________, 20__.

________________________________

Printed name:

County of Residence:_____________________

My Commission Expires:__________________


ACKNOWLEDGMENT OF WITNESS TO WAIVER OF NOTICE AND CONSENT TO

ADOPTION

The undersigned hereby acknowledges that the foregoing Waiver of Notice and Consent

by Biological Mother to Adoption of Her Minor Child was signed in the presence of the

undersigned by _(biological mother’s name)_, who appeared to be of sound mind, fully aware

of the implications and finality of signing a consent to adoption, and free of coercion, undue

influence, and duress.

_____________________________________

Printed:______________________WITNESS

STATE OF INDIANA )

) SS:

COUNTY OF MARION )

BEFORE ME, a Notary Public in and for said County and State, personally appeared

_(Witness’s name)_ and, being first duly sworn upon _(his/her)_ oath, acknowledged the

execution of the foregoing Acknowledgment of Witness, and, stated that the facts and matters

therein set forth are true and correct.

WITNESS my hand and seal, this _____ day of ____________, 20__.

Commission Expires: ____________ _________________________

Notary Public

Residing in _________ County, Indiana


Supplemental Form B

Form of pre-birth notice pursuant to IC 31-19-3-4

NOTICE OF THE POTENTIAL ADOPTION

_(putative father's name)_, who has been named as the father of the unborn child of

_(birth mother's name)_, or who claims to be the father of the unborn child, is notified that

_(birth mother's name)_ has expressed an intention to secure an adoptive placement for the

child.

If _(putative father's name)_ seeks to contest the adoption of the unborn child, the

putative father must file a paternity action to establish his paternity in relation to the unborn

child not later than thirty (30) days after the receipt of this notice.

If _(putative father's name)_ does not file a paternity action not more than thirty (30)

days after receiving this notice, or having filed a paternity action, is unable to establish

paternity in relation to the child under IC 31-14 or the laws applicable to a court of another

state when the court obtains jurisdiction over the paternity action, the putative father's consent

to the adoption or the voluntary termination of the putative father's parent-child relationship

under IC 31-35-1, or both, shall be irrevocably implied and the putative father loses the right to

contest the adoption, the validity of his implied consent to the adoption, the termination of the

parent-child relationship, and the validity of his implied consent to the termination of the

parent-child relationship. In addition, the putative father loses the right to establish paternity of

the child under IC 31-14 or in a court of another state when the court would otherwise be

competent to obtain jurisdiction over the paternity action, except as provided in IC 31-19-9-

17(b).

Nothing _(birth mother's name)_ or anyone else says to _(putative father's name)_

relieves _(putative father's name)_ of his obligations under this notice.

Under Indiana law, a putative father is a person who is named as or claims that he may

be the father of a child born out of wedlock but who has not yet been legally proven to be the

child's father.

For purposes of this notice, _(putative father's name)_ is a putative father under the

laws in Indiana regarding adoption.

____________________________________

Clerk of _____________Court


Supplemental Form C

Form of notice to parents and other persons when it is alleged that consent is not required

pursuant to IC 31-19-4.5-3

SUMMONS AND NOTICE OF ADOPTION

_(person's name)_ is notified that a petition for adoption of a child, named _(child's

name, if named)_, born to _(birth mother's name)_ on _(date)_ was filed in the office of the

clerk of _(county)_ court, _(address of the court)_. The petition for adoption alleges that the

consent to adoption of _(person's name)_ is not required because _(provide a brief description

of the reason(s) the consent is not required)_.

If _(person's name)_ seeks to contest the adoption of the child, _(person's name)_ must

file a motion to contest the adoption in accordance with IC 31-19-10-1 in the above named

court not later than thirty (30) days after the date of service of this notice.

If _(person's name)_ does not file a motion to contest the adoption within thirty (30)

days after service of this notice the above named court will hear and determine the petition for

adoption. The consent to adoption of _(person's name)_ will be irrevocably implied and

_(person's name)_ will lose the right to contest either the adoption or the validity of _(person's

name)_’s implied consent to the adoption.

No oral statement made to _(person's name)_ relieves _(person's name)_ of _(person's

name)_’s obligations under this notice.

This notice complies with IC 31-19-4.5-3 but does not exhaustively set forth a person's

legal obligations under the Indiana adoption statutes. A person being served with this notice

should consult the Indiana adoption statutes.

____________________________________

Clerk of _____________Court


Supplemental Form D

STATE OF INDIANA ) IN THE ____________SUPERIOR COURT

) SS: PROBATE DIVISION

COUNTY OF (COUNTY) ) CAUSE NO.______________________

IN THE MATTER OF: )

)

THE GUARDIANSHIP OF: )

)

_(child’s name)_, A Minor. )

PARENT’S CONSENT TO THE APPOINTMENT OF GUARDIAN(S)

OF THE PERSON OF MINOR CHILD

_(Parent’s name)_, being duly sworn upon his/her oath, says that he/she is an adult,

whose birth date is _(parent’s birth date)_, and is the parent of _(child’s name)_, whose birth

date is _(child’s birth date)_. _(Parent’s name)_ is familiar with the Petition for Appointment

of Guardian(s) of the person of _(child’s name)_ which _(guardian(s) name)_ plan(s) to file in

the above Court. _(Parent’s name)_ hereby consents to the appointment of _(guardian(s)

name)_ as Guardian(s) of the person of _(child’s name)_ and expressly waives service of

summons and notice of hearing on said guardianship petition.

____________________________________ ______________________________

(Parent’s Name; signature above) Date

Sworn to me and subscribed in my presence, a Notary Public in and for the State of Indiana,

County of __________________ this ____________ day of ___________, 20__.

_______________________________

Notary Public


Supplemental Form E

STATE OF INDIANA ) IN THE _______________ (COUNTY) COURT

) SS:

COUNTY OF ___________ ) CAUSE NO. _____________________________

IN THE MATTER OF THE TERMINATION )

OF THE PARENT-CHILD RELATIONSHIP )

OF: )

_(child’s name)_, a child, )

and )

_(parent(s) name(s))_, the child’s parent(s). )

JOINT PETITION FOR INVOLUNTARY TERMINATION

OF THE PARENT-CHILD RELATIONSHIP

Comes now the Department of Child Services, by counsel, _(DCS attorney’s name)_,

and the CASA/GAL, _(CASA/GAL’s name)_, and respectfully petition the Court for

termination of the parent-child relationship between _(child’s name)_, minor child and the

_(parent(s)/Mother/Father, list name(s))_. This request is made pursuant to Ind. Code 31-35-

2-4, and in support of this request, your petitioners would respectfully show the Court as

follows:

1. That one of the following is true:

a. The child has been removed from the parent for at least six (6) months under a

dispositional decree; or

b. A court has entered a finding under Ind. Code 31-34-21-5.6 that reasonable efforts

for family preservation or reunification are not required. The finding was made on

_(date)_ via _(manner in which finding was made)_. The findings were as follows:

_(include description of court’s findings)_; or

c. The child has been removed from the parent and has been under the supervision of a

local office of family and children or probation department for at least fifteen (15)

months of the most recent twenty-two (22) months, beginning with the date the

child is removed from the home as a result of the child being alleged to be a Child in

Need of Services or a delinquent child.


2. That one of the following circumstances is true:

a. There is a reasonable probability that the conditions that resulted in the child’s

removal or the reasons for placement outside the home of the parents will not be

remedied; or

b. There is a reasonable probability that the continuation of the parent-child

relationship poses a threat to the well-being of the child; or

c. The child has, on two (2) separate occasions, been adjudicated a child in need of

services.

3. Termination is in the best interests of the child.

4. There is a satisfactory plan for the care and treatment of the child.

5. The Department of Child Services and the CASA/GAL do not intend to file a motion to

dismiss under Ind. Code 31-35-2-4.5(d). None of the factors listed at Ind. Code 31-35-

2-4.5(d) apply to this petition.

Respectfully submitted,

_______________________________________

Attorney for Department of Child Services

________________________________________

CASA/GAL

CERTIFICATION OF SERVICE

I hereby certify that a copy of the foregoing has been mailed to

____________________________________________________________________________

____________________________________________________________________________

this _________ day of __________, 20____.

_______________________________________

Attorney for Department of Child Services


Supplemental Form F

STATE OF INDIANA ) IN THE _______________ (COUNTY) COURT

) SS:

COUNTY OF ___________ ) CAUSE NO. _____________________________

IN THE MATTER OF THE TERMINATION )

OF THE PARENT-CHILD RELATIONSHIP )

OF: )

_(child’s name)_, a child, )

and )

_(parent(s) name(s))_, the child’s parent(s). )

MOTION TO DISMISS PETITION FOR TERMINATION

OF THE PARENT-CHILD RELATIONSHIP

Comes now _________________, counsel for _(DCS or the CASA/GAL)_ and

respectfully moves the Court to dismiss the petition for termination of the parent-child

relationship filed in the above case. In support of this Motion, _(DCS or the CASA/GAL)_

would respectfully show the court that one of the following exists pursuant to IC 13-35-2-

4.5(d):

(____) 1. That the current case plan prepared by or under the supervision of the department of

child services or the probation department under IC 31-34-15, IC 31-37-19-1.5, or

IC 31-37-22-4 has documented a compelling reason, based on facts and circumstances

stated below, for concluding that filing, or proceeding to a final determination of, a

petition to terminate the parent-child relationship is not in the best interests of the child.

The reasons are as follows:

(A) _(list reasons)_.

(B) _(list reasons)_.

(____) 2. That:

(A) IC 31-34-21-5.6 is not applicable to the child.

(B) The department of child services or the probation department has not

provided family services to the child, parent, or family of the child in

accordance with a currently effective case plan prepared under IC 31-34-15

or IC 31-37-19-1.5 or a permanency plan or dispositional decree approved


under IC 31-34 or IC 31-37, for the purpose of permitting and facilitating

safe return of the child to the child’s home; and

(C) The period for completion of the program of family services, as specified in

the current case plan, permanency plan, or decree, has not expired.

(____) 3. That:

(A) IC 31-34-21-5.6 is not applicable to the child;

(B) The department of child services has not provided family services to the

child, parent, or family of the child, in accordance with applicable

provisions of a currently effective case plan under IC 31-34-15 or IC 31-37-

19-1.5, or a permanency plan or dispositional decree approved under IC 31-

34 or IC 31-37; and

(C) The services that the department has not provided are substantial and

material in relation to implementation of a plan to permit safe return of the

child to the child’s home.

Wherefore, counsel for _(DCS or the CASA/GAL)_ respectfully requests that the petition

for termination of the parent-child relationship be dismissed.

Respectfully submitted,

_______________________________________

Attorney for _(DCS or the CASA/GAL)_

Attorney information

CERTIFICATION OF SERVICE

I hereby certify that a copy of the foregoing has been mailed to

____________________________________________________________________________

____________________________________________________________________________

this _________ day of __________, 20____.

_______________________________________

Attorney for _(DCS or the CASA/GAL)_


Supplemental Form G




)

IN THE MATTER OF: )

)


)


VERIFIED PETITION FOR APPOINTMENT OF TEMPORARY GUARDIANS

WITHOUT NOTICE AND HEARING

Come now the petitioners, _(proposed guardians’ names)_ by counsel, _(counsel’s name)_, and

respectfully petition the Court to appoint them as temporary guardians of _(child’s name)_. In

support of this request, the petitioners would respectfully show the Court as follows:

1. _(child’s name)_ currently resides with the petitioners at _(street address)_, _(city)_,

Indiana.

2. _(child’s name)_ was born on _(date of birth)_ and is ___ years old, and is incapacitated

due to his/her minority.

3. _(child’s name)_ has no real property or personal property other than some clothing. OR

_(child’s name)_ has the following real and/or personal property: _(list all real and/or

personal property)_.

4. The petitioners _(have not/have)_been appointed guardians of any other person in any state.

(If petitioners have been appointed as guardians of any other person, list relevant

information, including names and address of the other incapacitated individuals or minors)

5. The petitioners _(are/are not)_ aware of another guardian appointed or acting for _(child’s

name)_. (If aware of another guardian, list relevant information)

6. The petitioners reside at _(street address)_, _(city)_, Indiana and their relationship to

_(child’s name)_ is that of _(relationship)_.

7. The names and addresses as far as known or can reasonably be ascertained, of the

persons most closely related by blood or marriage to _(child’s name)_ are:


a. _(mother’s name)_whose (last known address) was/is _(street address)_,

_(city)_, _(state)_. (AND/OR Petitioners do not have a current address for the

mother, and her whereabouts are currently unknown to them.)

b. _(child’s name)_ was born out of wedlock, and petitioners do not believe that a

paternity affidavit has been executed nor that paternity has been established by a

judicial proceeding. OR _(child’s name)_ was born out of wedlock. Petitioners

believe that a paternity affidavit has been executed, but no judicial proceeding to

establish custody, parenting time, or child support has commenced.

c. The petitioners’ last known address for the (alleged) father, _(father’s name)_,

is _(street address)_, _(city)_, _(state)_.

d. The _(other relative of child identified by relationship to child)_of _(child’s

name)_ is _(other relative’s name)_, who resides at _(street address)_, _(city)_,

_(state)_.

8. The petitioners have had physical care and custody of _(child’s name)_ since _(date)_

when _(child’s name)_ was left with petitioners by _(name of person who left child)_.

OR _(person’s name, relationship to child)_has had physical care and custody of

_(child’s name)_ since _(date)_. _(person’s name) resides at _(street address)_, _(city)_,

_(state)_.

9. The appointment of a temporary guardian is sought for the following reasons:

a. No guardian has been appointed for _(child’s name)_, an emergency exists, and

the welfare of _(child’s name)_, requires immediate action, and no other person

appears to have authority to act in the circumstances.

b. The nature of the emergency is _(explain details of emergency)_.

c. The immediate action required on behalf of _(child’s name)_ is _(state facts)_.

The petitioners are able and willing to undertake said action if the Court grants their

petition.

d. Immediate and irreparable injury to the person of _(child’s name)_ may result

unless the Court grants said temporary guardianship without notice and hearing.

10. The petitioners are requesting to be appointed temporary guardians because of _(list

reasons)_, and the petitioners’ interest in the appointment is _(describe interest)_.

11. The name and business address of the attorney who is representing the petitioners is

_(attorney’s name and address)_.


12. Notice of this petition is being served on the persons listed in paragraph number six of the

petition pursuant to IC 29-3-6 or IC 29-3-3-4.

13. A Child In Need Of Services petition and/or a program of informal adjustment

_(has/has not)_been filed regarding _(child’s name)_. (If so, state whether the case

regarding the minor is open at the time the guardianship petition is filed)

14. The filing fee in this action has been paid.

Wherefore, the petitioners respectfully request to be appointed temporary guardians of

_(child’s name)_, pending notice and hearing. The petitioners further request that the Court find

that a guardian has not been appointed for _(child’s name)_, an emergency exists, the _(child’s

name)_ requires immediate action, no other person appears to have authority to act, and irreparable

injury to the person of _(child’s name)_ may result if said temporary guardianship is not granted.

We solemnly swear or affirm, under penalty for perjury, that the foregoing facts and representations

are true to the best of our knowledge and belief.

__________________________________ __________________________________

(proposed guardian) (proposed guardian)

Attorney Information and signature


Supplemental Form H




IN THE MATTER OF: )

)


)


ORDER GRANTING VERIFIED PETITION FOR APPOINTMENT

OF TEMPORARY GUARDIANS PENDING NOTICE AND HEARING

Come now the petitioners, _(proposed guardians’ names)_, by counsel, _(counsel’s name)_

and file their Verified Petition for Appointment of Temporary Guardians Without Notice and

Hearing. And the Court, having read and reviewed said Petition, enters the following findings

and orders:

1. That _(child’s name)_ is incapacitated due to his/her minority.

2. That _(child’s name)_ has no real property or personal property other than some

clothing and toys. OR _(child’s name)_ has the following real and/or personal property:

_(list all real and/or personal property)_.

3. That the petitioners _(have/have not)_ been appointed guardians of any other person in

this state. (If petitioners have been appointed as guardians of any other person, list

relevant information, including names and address of the other incapacitated individuals or

minors)

4. That _(child’s name)_ was born out of wedlock.

5. The petitioners have had physical care and custody of _(child’s name)_ since _(date)_

when _(child’s name)_ was left with petitioners by _(name of person who left child)_.

OR _(person’s name, relationship to child)_ has had physical care and custody of

_(child’s name)_ since _(date)_.

6. That no guardian has been appointed for _(child’s name)_ that an emergency exists that

the welfare of _(child’s name)_ requires immediate action concerning _(list

circumstances)_.


7. That immediate and irreparable injury to the person of _(child’s name)_ may result

unless the Court grants temporary guardianship to petitioners without notice and

hearing.

8. That the petitioners are suitable and willing to serve as temporary guardians of _(child’s

name)_ .

9. That said temporary guardianship is necessary and in _(child’s name)_ best interest.

10. That a hearing on said guardianship shall be scheduled for the _________________ day of

____________________, 20___, at _____.m., and that notice shall be given to the persons

most closely related to _(child’s name)_ as listed in the petition, by the best means

possible, pursuant to IC 29-3-6.

11. That _(petitioners’ names)_ are hereby appointed temporary guardians of _(child’s name)_,

without limitations on their duties, pending the hearing, and the Clerk shall issue Letters of

Temporary Guardianship to the petitioners.

Dated: _________________ __________________________________________

Judge, Court Name, Probate Division

DISTRIBUTION:

Parties’ names and addresses

Attorneys’ names and addresses


Supplemental Form I




IN THE MATTER OF: )

)


)


VERIFIED PETITION FOR APPOINTMENT OF GUARDIANS

OF THE PERSON OF MINOR

Comes now the petitioners, _(proposed guardians’ names)_, by counsel, _(counsel’s

name)_, and respectfully petition the Court to appoint them as guardians of _(child’s name)_.

In support of this request, the petitioners would respectfully show the Court as follows:

1. _(child’s name)_ was born on _(date)_ and is ____ years old and is incapacitated due to

his/her minority.

2. _(child’s name)_ currently resides with the petitioners at _(street address)_, _(county)_,

Indiana. The petitioners have had physical care and custody of _(child’s name)_ since

_(date)_ when _(child’s name)_ was left with petitioners by _(name of person who left

child)_. OR _(person’s name, relationship to child)_ has had physical care and custody

of _(child’s name)_ since _(date)_. _(person’s name) resides at _(street address)_,

_(city)_, _(state)_.

3. The petitioners are the child’s _(state relationship)_. The petitioners have been

supporting and caring for the child.

4. A Child In Need Of Services petition and/or a program of informal adjustment

_(has/has not)_ been filed regarding _(child’s name)_. (If so, state whether the case

regarding the minor is open at the time the guardianship petition is filed)

5. The petitioners _(are/are not)_ aware of another guardian appointed or acting for _(child’s

name)_ . (If aware of another guardian, list relevant information)

6. _(child’s name)_ has no real property or personal property other than some clothing and

toys. OR _(child’s name)_ has the following real and/or personal property: _(list all real

and/or personal property)_.


7. The names and addresses as far as known or can reasonably be ascertained, of the

persons most closely related by blood or marriage to _(child’s name)_ are:

a. _(mother’s name)_ whose (last known address) was/is _(street address)_,

_(city)_, _(state)_. (AND/OR Petitioners do not have a current address for the

mother, and her whereabouts are currently unknown to them.)

b. _(child’s name)_ was born out of wedlock, and petitioners do not believe that a

paternity affidavit has been executed nor that paternity has been established by a

judicial proceeding. OR _(child’s name)_ was born out of wedlock. Petitioners

believe that a paternity affidavit has been executed, but no judicial proceeding to

establish custody, parenting time, or child support has commenced.

c. The petitioners’ last known address for the (alleged) father, _(father’s name)_,

is _(street address)_, _(city)_, _(state)_.

d. The _(other relative of child identified by relationship to child)_ of _(child’s

name)_ is _(other relative’s name)_, who resides at _(street address)_, _(city)_,

_(state)_.

8. The appointment of a temporary guardian is sought for the following reasons:

a. Mother is unavailable to care for _(child’s name)_ , due to _(state reasons)_.

b. _(father/alleged father)_ is unavailable to care for _(child’s name)_ , due to _(state

reasons)_.

c. _(petitioners names)_, if appointed guardians, can receive health insurance

through their employment and can provide _(child’s name)_ with a secure, stable

home.

9. The name and business address of the attorney who is representing the petitioners is


10. Notice of this petition is being served on the mother and the alleged father by _(state

manner of service)_.

11. The filing fee for this proceeding has been paid.

12. The petitioners request that no bond be required of them since _(child’s name)_ has no

assets. (if applicable)

13. That the petitioners _(have/have not)_ been appointed guardians of any other person in

this state. (If petitioners have been appointed as guardians of any other person, list


relevant information, including names and address of the other incapacitated individuals or

minors)

Wherefore, the petitioners respectfully request to be appointed guardians of

_(child’s name)_ after notice and hearing. The petitioners further request that the Court find that

the parental presumption has been rebutted by evidence of parental unfitness, abandonment of

_(child’s name)_ , and evidence of other factors, and that their guardianship of _(child’s name)_ is

in the child’s best interests and presents a substantial and significant advantage to _(child’s

name)_.

The petitioners further respectfully request that the Court Order _(supervised

visitation/other visitation)_ for _(parents) __ with _(child’s name)_, and the petitioners are

willing to supervise said visitation at mutually convenient times and places.

We solemnly swear or affirm, under penalty for perjury, that the foregoing facts and

representations are true to the best of our knowledge and belief.

___________________________ ________________________________

(petitioner) (petitioner)

Attorney information and signature


Supplemental Form J




IN THE MATTER OF: )

)


)


ORDER FOR APPOINTMENT OF GUARDIANS OF THE PERSON OF MINOR

OPTION: On _(date)_, this Court issued an Order Granting Emergency Petition for the

Appointment of Temporary Guardians of the Person over minor whereby _(temporary

guardians’ names)_ were made temporary guardians over _(child’s name)_, minor.

On _(date)_, a hearing was held to determine whether the _(temporary/prospective)_

guardians should be appointed guardians. Petitioners, _(petitioners’ names)_ appeared with

counsel, _(attorney’s name)_; _(list any other parties that appeared as well as their counsel)_.

After the evidence was presented and being duly advised in the premises, the Court now enters

the following facts and conclusions and issues this Order:

1. That the Court has jurisdiction over the parties and the subject matter in this case.

2. That _(child’s name)_ is ___ years old, being born on _(child’s date of birth)_, and is

incapacitated due to minority.

3. That the minor child does not possess any property, personal or real, for which to

account. OR _(child’s name)_ has the following real and/or personal property: _(list all

real and/or personal property)_.

4. That no other guardian has been appointed or is acting for the minor child.

5. That the name and business address of the attorney who represents the guardians is


6. That the appointment of a guardian is necessary as a means of providing care and

supervision of the physical person of the minor child, pursuant to IC 29-3-5-3.

7. That the mother, _(mother’s name)_, and the father of the minor child, _(father’s

name)_, both consent and agree to the appointment of _(petitioners’ names)_ as


guardians of _(child’s name)_. OR That the parental presumption in favor of the

_(mother and/or father)_ has been overcome by evidence of the _(mother’s and/or

father’s)_ (unfitness; long acquiescence; voluntary relinquishment such that the

affections of the child and the petitioners have become so interwoven that to sever them

would seriously mar and endanger the future happiness of the child; other factors; and

that placement with petitioners represents a substantial and significant advantage to the

child).

8. That the weekly child support being paid by _(father and/or mother)_ for the benefit of

minor child, _(child’s name)_, shall now be forwarded to the guardians _(petitioners’

names)_ at their residence, which is _(petitioners’ address)_, until further notice of this

Court.

IT IS, THEREFORE, ORDERED that Petitioners, _(petitioners’ names)_, are hereby appointed

as legal guardians of _(child’s name)_, minor child, and that said guardians shall serve without

bond, and that the clerk shall issue Letters of Guardianship without any limitations to said

guardians upon their taking an oath. Said guardians are authorized to exercise all powers

granted guardians of the person of a minor as set forth in IC 29-3-8-1 through IC 29-3-8-4.

SO ORDERED ON: THIS ________ DAY OF ______________, 20___.

_________________________________

JUDGE

_(County)_ COUNTY SUPERIOR COURT

Distribution:

Parties’ names and addresses



Supplemental Form K

STATE OF INDIANA ) IN THE _______________ CIRCUIT COURT

) SS: COUNTY OF _________________________

) CAUSE NO. __________________________

IN RE THE PATERNITY OF: ) _( child’s name)_, )

minor child. )

)

BY NEXT FRIEND: )

)

_(parent’s name)_ )

PETITIONER – (FATHER/MOTHER) )

)

AND )

)


RESPONDENT – (FATHER/MOTHER) )

)

_(Intervener’s name(s))_ )

INTERVENERS. )

CHILD IN NEED OF SERVICES DISCLOSURE FORM

Comes now _(mother/father/interveners)_, and respectfully files _(her/his/their)_ CHINS

Disclosure Form. Pursuant to IC 31-14-13-12, _(mother/father/interveners)_ disclose to the

Court, under seal, that:

1. A petition to modify or establish custody of the child, _(child’s name)_, has been filed

by _(mother/father/interveners)_ in the above cause number.

2. _(mother/father/interveners)_ _(is/are)_ _(a party/parties)_ _(OR: I/we am/are

requesting to be a party/parties to)_ the custody proceedings in the above cause

number.

3. I have knowledge that (select one):

a. _(name of party)_, who is party to these custody proceedings in the above cause

number, has been determined to be a perpetrator of a substantiated report of

child abuse or neglect; OR

b. The child named in the petition for modification of custody in the above cause

number, _(child’s name)_, has been the subject of a substantiated report of child

abuse or neglect; OR


c. The child named in the petition for modification of custody in the above cause

number, _(child’s name)_, has been determined to be a child in need of services

under IC 31-34; OR

d. The child named in the petition for modification of custody in the above cause

number, _(child’s name)_, has been involved in an informal adjustment under

IC 31-34-8.

4. _(mother/father/interveners)_ understand(s) _(her/his/their)_ duty under IC 31-14-13-

12 to continue to keep the Court informed, in writing, of any changes to this

information.

5. _(mother/father/interveners)_ understand(s) that if this information is not given to the

Court, a hearing on the petition regarding custody may be delayed until the information

is provided to the Court.

6. _(mother/father/interveners)_ understand(s) that the Court reviewing the petition to

establish or modify custody of the child may request information from the Department

of Child Services regarding the custody petition or the proceedings described in IC 31-

14-13-12(a)(2).

7. _(mother/father/interveners)_ understand(s) that the Department of Child Services is

required to provide a response, under seal, to the Court’s request for information.

_____________________________ __________________________

Date (Party’s name and signature)



Supplemental Form L


) SS: COUNTY OF _________________________

) CAUSE NO. __________________________

IN RE THE PATERNITY OF: )

_( child’s name)_, )

minor child. )

)

BY NEXT FRIEND: )

)



)

AND )

)



)


INTERVENERS. )

VERIFIED MOTION TO INTERVENE AND BE JOINED AS NECESSARY PARTIES

AND PETITION FOR MODIFICATION OF CUSTODY

Come now _(petitioner’s name(s))_, hereinafter _(petitioner’s relationship to child)_, and

respectfully file their Verified Motion to Intervene and Be Joined as Necessary Parties and

Petition for Modification of Custody. In support of these requests, _(petitioners)_ would

respectfully show the Court as follows:

1. _(child’s name)_ was born out of wedlock to Mother, _(mother’s name_, and is now

____ years old.

2. Paternity was established for _(child’s name)_ on _(date)_.

3. Pursuant to the _(date; agreement/order)_, legal custody of _(child’s name)_ was

awarded to _(Mother/Father)_ and _(Mother/Father)_ was awarded parenting time

_(per the Indiana Parenting Time Guidelines/describe other)_. _(Mother/Father)_ was

ordered to pay _(amount)_ per week in child support to _(Mother/Father)_via Income

Withholding Order.

4. Since the date of the _(Order/Agreement)_, the following events have occurred:


a. _(List circumstances relevant to Mother, such as pending criminal matters or

recent convictions [list cause numbers], incarceration, drug use, untreated

mental health problems, domestic violence, inability to maintain employment or

a residence, etc.)_.

b. _(List circumstances relevant to Father, such as pending criminal matters or

recent convictions [list cause numbers], incarceration, drug use, untreated

mental health problems, domestic violence, inability to maintain employment or

a residence, etc.)_.

c. _(List circumstances relevant to child, such as needing medical care which is

not being provided, needing to be enrolled in school, needing a stable home;

etc)_.

d. _(If child is living with petitioners, state length of time and reasons why child is

living with petitioners)_.

5. _(petitioners)_ seek intervention to request that the Court appoint them as Third Party

Custodians of _(child’s name)_.

6. The _(petitioners)_ reside at _(street address)_, _(county)_, _(state)_.

7. The _(petitioners)_ believe that _(child’s name)_’s best interests would be substantially

and significantly served by placement with them based upon the following:

a. _(petitioners)_ have been married for ___ years.

b. _(petitioners)_ have been employed at _(employers’ names)_ for __ years and

can provide health insurance for _(child’s name)_.

c. _(petitioners)_ own their home where _(child’s name)_ has his/her own

bedroom.

8. _(petitioners)_ request that the Court permit them to intervene as necessary parties

pursuant to Indiana Trial Rule 24(B) because the child currently is living in their home,

and they are requesting to be appointed third party custodians.

9. _(petitioners)_ have a claim in common with the paternity proceeding in this cause.

10. The _(petitioners)_ further request that the Court order _(supervised visitation/other

parenting time)_ for Mother and _(supervised visitation/other parenting time)_ for

Father.


Wherefore, the _(petitioners)_ respectfully request that the Court permit

them to intervene in this matter, and schedule a hearing on their Petition to Modify Custody.

We solemnly swear or affirm, under the penalty for perjury, that the foregoing facts

and representations are true to the best of our knowledge and belief.

_____________________________ __________________________

(Petitioner name and signature) (Petitioner name and signature)



Supplemental Form M


) SS: COUNTY OF _________________________

) CAUSE NO. __________________________

IN RE THE PATERNITY OF: )

_( child’s name)_, )

minor child. )

)

BY NEXT FRIEND: )

)



)

AND )

)



)


INTERVENERS. )

ORDER GRANTING MOTION TO INTERVENE

Come now the _(petitioners’ relationship to child)_, _(petitioner’s name)_ and

_(petitioner’s name)_, by counsel _(attorney name)_ and file their Verified Motion to Intervene

and Be Joined as Necessary Parties and Petition for Modification of Custody.

And the Court, having read and reviewed said Motion and Petition, now finds that the

_(petitioners’ relationship to child)_ are hereby permitted to intervene in the above cause

pursuant to Indiana Trial Rule 24(B) for the purpose of providing evidence on their Petition for

Modification of Custody. The Court now schedules the Petition for Modification of Custody for

hearing on the __________ day of ___________________, 20__, at __________.M.

Counsel for the Intervener _(petitioners’ relationship to child)_ is directed to serve a copy

of this Order on Mother and Father.

Date: ____________________ __________________________________

Judge

(County) Circuit Court

DISTRIBUTION: Parties’ names and addresses



Supplemental Form N


) SS: COUNTY OF _________________________

) CAUSE NO. __________________________

IN RE THE PATERNITY OF: ) _( child’s name)_, )

minor child. )

)

BY NEXT FRIEND: )

)



)

AND )

)



)


INTERVENERS. )

ORDER GRANTING INTERVENERS’ PETITION FOR MODIFICATION OF

CUSTODY

Comes now the Mother, _(mother’s name; Petitioner/Respondent)_, in person and by counsel,

_(attorney’s name)_, the Father, _(father’s name; Petitioner/Respondent)_, in person and by

counsel, _(attorney’s name)_, and the Interveners _(petitioners’ relationship to child)_,

_(petitioner’s name)_ and _(petitioner’s name)_, in person and by counsel _(attorney name)_

for hearing on the Interveners’ Petition for Modification of Custody. Witnesses were sworn,

and evidence was heard and concluded. The Court now enters the following findings and

orders:

1. The rebuttable presumption in favor of Mother’s custody of the child has been

overcome by the following clear and convincing evidence:

a. _(List evidence relevant to Mother, such as pending criminal matters or recent

convictions [list cause numbers], incarceration, drug use, untreated mental

health problems, domestic violence, inability to maintain employment or a

residence, etc.)_.


2. The rebuttable presumption in favor of Father’s custody of the child has been overcome

by the following clear and convincing evidence:

a. _(List evidence relevant to Father, such as pending criminal matters or recent

convictions [list cause numbers], incarceration, drug use, untreated mental

health problems, domestic violence, inability to maintain employment or a

residence, etc.)_.

3. Placing _(child’s name)_in the custody of the Intervener _(petitioners)_ is in the child’s

best interests because:

a. _(petitioners)_ have been married for __ years and have a stable home.

b. _(petitioners)_ have been employed by _(employers’ names)_ for __ years and

can provide health insurance for _(child’s name)_ obtain health insurance for

and financially support the child.

c. _(petitioners)_ own their home and the child has his/her own bedroom.

4. The Intervener Maternal Grandparents are appointed legal and physical custodians of

_(child’s name)_.

5. Mother shall have parenting time _(describe parenting time, conditions, persons who

may supervise, times, locations, etc.)_.

6. Father shall have parenting time _(describe parenting time, conditions, persons who

may supervise, times, locations, etc.)_.

7. _(Person’s name)_ is appointed to serve as a temporary conditional custodian in the

event of the death or disability of the _(petitioners)_. _(Person’s name)_ resides at

_(street address)_, _(county)_, _(state)_, his/her telephone number is _______, and

counsel for _(petitioners)_ shall send her a copy of this Order.

8. Counsel for _(Mother, petitioners, or Father)_ shall submit a child support worksheet

within 30 days so that a child support order can be entered.

__________________ ___________________________________

Date Judge

(COUNTY) CIRCUIT COURT

DISTRIBUTION: Parties’ names and addresses



Supplemental Form O

POST ADOPTION CONTACT AGREEMENT

This agreement is entered into pursuant to Indiana Code § 31-19-16-2 by and between

_(petitioner’s name)_ and _(petitioner’s name)_, collectively referred to herein as Adoptive

Parents, who are the prospective adoptive parents of _(child’s name)_, minor child over the age

of two (2) years and under the age of twelve (12) years, and _(biological parent’s name)_,

biological parent of said child, herein referred to as Biological Parent. All parties have had the

benefit of counsel prior to entering into this agreement. The parties agree that the adoption of

_(child’s name)_ by Adoptive Parents is in _(child’s name)_’s best interest and that continued

contact with Biological Parent, under certain conditions, is also in _(child’s name)_’s best

interest.

Biological Parent is contemporaneously executing a consent to the adoption of _(child’s

name)_ by Adoptive Parents. Biological Parent acknowledges that _(he/she)_ understands that

this consent is irrevocable and that _(he/she)_ consents of _(his/her)_ own free will and not as a

result of duress, inducement or intimidation. Biological Parent further acknowledges that the

adoption is irrevocable even if the adoption court does not approve this agreement.

Adoptive Parents acknowledge that this agreement grants Biological Parent the right to seek

to enforce the post adoption privileges set forth in the agreement. Biological Parent

acknowledges that the adoption is irrevocable even if Adoptive Parents do not abide by the post

adoption contact agreement. All parties acknowledge that they have been provided a copy of

the post adoption contact (“open adoption”) statute, Indiana Code § 31-19-16-2.

The parties, having contemplated and negotiated the terms of this agreement and having

consulted with the licensed child placing agency which is sponsoring this adoption and the

child’s Guardian Ad Litem appointed by the court presiding over the termination of parental

rights proceedings, now agree as follows:

1. Adoptive Parents will make the child available for visitation with Biological Parent as

often as _______ times per year, spaced at least _______ months apart, starting from

the date this agreement is approved by the adoption court at the adoption hearing unless

Adoptive Parents, in their sole discretion, agree to allow additional visits.

2. Arrangements for the visitation shall be initiated by Biological Parent thirty (30) days in

advance of the requested date via email. Adoptive Parents’ email address is

________________. Visitation will not occur on _(child’s name)_’s birthday or any

holiday unless Adoptive Parents agree. Adoptive Parents may then choose a date up to

________ weeks earlier or _______ weeks later than the proposed date if Biological

Parent’s proposed date conflicts with Adoptive Parents’ schedule. The parties will use

their best efforts to select a mutually convenient time for the visits.

3. Visitation will occur at a mutually agreeable place. If the parties cannot agree,

visitation will occur at a public place designated by Adoptive Parents such as a

children’s museum, zoo, restaurant or shopping center. Adoptive Parents will bear any

costs of admission for all of the parties.


4. Adoptive Parents or their designees will remain with _(child’s name)_ during the course

of the visit unless they decide otherwise.

5. Each visit will end whenever the parent chooses but in no event shall such visit last

longer than __________ hours unless Adoptive Parents or their designee agrees

otherwise.

6. No photographs shall be taken of _(child’s name)_ during the visit.

7. Biological Parent will bear the costs for transportation to the visits even if _(he/she)_ or

Adoptive Parents no longer reside in Marion County, Indiana. Adoptive Parents or

Biological Parent move more than thirty (30) miles outside Marion County, Biological

Parent may visit by telephone.

8. If at any time _(child’s name)_’s therapist or counselor determines, in writing, that the

terms of contact contained in this agreement are not in the best interest of _(child’s

name)_, this agreement shall be suspended until such time as _(child’s name)_’s

therapist or counselor determines, in writing, that the terms of contact contained in this

agreement should resume. Adoptive Parents shall provide the parent with a copy of any

written determination from _(child’s name)_’s therapist or counselor regarding

visitation.

9. _(child’s name)_ shall have the right to refuse a visit, and the visit will not be

rescheduled.

10. Biological Parent will not bring any other person to the visits.

11. Neither party shall make any disparaging remarks about the other in the presence of

_(child’s name)_, or during contact necessary to scheduling visitation.

12. If the visit supervisor, at his or her sole discretion, determines that Biological Parent is

under the influence of drugs or alcohol, the visit will end, and will not be rescheduled.

13. The parties will keep each other advised of any changes in their addresses and telephone

numbers or they will designate agents who will be able to contact the parties

immediately and any changes in the agents’ addresses and telephone numbers will be

forwarded to the other party.

14. Biological Parent may send, to Adoptive Parents, appropriate gifts, letters, photographs,

and cards to give to _(child’s name)_ on national and religious holidays and _(child’s

name)_. Adoptive Parents will determine if the gift, letter, photograph or card or gift is

inappropriate. In such case, Adoptive Parents will contact Biological Parent to advise

why _(child’s name)_ was not given the gift, letter, photograph or card.

15. If Biological Parent fails to visit for a period of one (1) year, his/her post adoption

privileges are terminated.

16. Neither Biological Parent nor any agent of Biological Parent may communicate with the

children electronically, telephonically, or in any way not provided for in this agreement,

even if the children initiate the contact. If Biological Parent, or an agent of Biological

Parent, communicates or attempts to communicate with the children electronically,

telephonically, or in any way not provided for in this agreement, Biological Parent will

be considered in violation of this agreement, and this agreement will be automatically

terminated.

17. Once each year, Adoptive Parents will send to Biological Parent a photograph _(child’s

name)_. If Biological Parent, or an agent of Biological Parent, posts these photographs

of _(child’s name)_on the internet or any social media, Biological Parent will be


considered in violation of this agreement and _(this agreement will automatically

terminate/ Adoptive Parents will no longer have to comply with this provision)_.

18. If, subsequent to the execution of this agreement, Biological Parent is incarcerated or

institutionalized, this post adoption agreement will be suspended for the duration of the

incarceration or institutionalization unless Biological Parent is incarcerated or

institutionalized for over six (6) months, in which case this post adoption agreement

will terminate.

19. Waiver of any of the provisions of this agreement does not constitute waiver of any

other provision. Modifications of this agreement must be made in writing and signed

by all parties.

20. Neither party may bring a petition to modify or void this agreement pursuant to the

above cited statute or in equity or for any other reason unless that party signs a verified

petition which swears that the agreement should be voided or modified and stating with

specificity the facts supporting the allegations. The parties waive their rights to an

automatic hearing as required in the statute and agree that the court may dismiss the

petition or grant summary judgment based on the petition, any other pleadings filed, or

the report from the GAL. A party who files such a petition may not file another petition

for one year unless there are substantially different or additional facts to support the

request.

_______________________________ _______________________________

_(petitioner’s name)_ _(petitioner’s name)_

Adoptive Parent Adoptive Parent

_______________________________

_(attorney name and information)_

Attorney for Adoptive Parents

_______________________________

_(biological parent’s name)_,

Biological Parent of Child

_______________________________

_(attorney name and information)_

Attorney for Biological Parent

THE UNDERSIGNED RECOMMEND THAT THIS AGREEMENT BE APPROVED BY

THE COURT.

____________________________ _______________________________

Guardian Ad Litem Licensed Child Placing Agency


If the child is at least 12 years of age, that child has to sign this agreement, and this language

must be included here:

BY MY SIGNATURE BELOW, I STATE THAT I HAVE READ AND UNDERSTAND

THIS AGREEMENT, AND THAT I HEREBY GIVE MY CONSENT TO THIS

AGREEMENT:

____________________________

_(child’s name)_

APPROVED BY THE COURT:

DATE: _______________________

______________________________

JUDGE, Probate Court

WAIVER OF NOTICE AND CONSENT BY BIOLOGICAL...

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