Adoptive Parents Affidavit And Petition To Appoint A Confidential Intermediary {WYCAI-5}

WYCAI-5 (1/27/11) ) ) COUNTY OF ________________________) IN THE MATTER OF THE ADOPTION OF STATE OF WYOMING IN THE DISTRICT COURT SS ______________JUDICIAL DISTRICT ) ) ) ) ) ) CASE # _________________________ ADOPTIVE PARENT'S AFFIDAVIT AND PETITION TO APPOINT A CONFIDENTIAL INTERMEDIARY, PURSUANT TO W.S. 1-22-203(b) _______________________________ ___________________________________________, being first duly sworn, on oath, petitions and says: (petitioner's name) My current telephone numbers are: (home) ____________________(work) _______________________ (cell)_____________________________. E-mail address _____________________________________ Mailing address_______________________________________________________________________. My adoptive son/daughter was born in _______________________________________________ (city/county) on _______________________________and is 18 years of age or older. (date of birth) Date of adoption: _______________________________________________________________. The adoption took place at: ______________________________________________________. Names of adoptive parents at time of adoption: ________________________________________ Birth parents' names, if known: ____________________________________________________ I know the following about my adoptive son's/daughter's birth family: _____________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I am seeking my adoptive son's/daughter's birth family because: _________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I, therefore, petition this court and respectfully request that an order be entered appointing a confidential intermediary, pursuant to W.S. 1-22-203(b) and that the confidential intermediary be allowed to inspect and copy, at the petitioner's expense, the pertinent adoption files of the court, governmental agencies, adoption agencies and hospitals. DATED this ______________day of ___________________________________________, 20 _______. _____________________________________________ (Petitioner's signature) SUBSCRIBED AND SWORN to before me this __________ day of __________________, 20________. My commission expires: ___________________________________ _____________________________________________ NOTARY PUBLIC OR DEPUTY CLERK OF COURT American LegalNet, Inc. www.FormsWorkFlow.com