Here is the text we could read:
COURT OF COMMON
PLEAS OF
COUNTY
ORPHANS' COURT DIVISION
IMPORTANT NOTICE
NOTICE OF PARENTAL RIGHTS TO PROVIDE MEDICAL INFORMATION
AND DETERMINE
ACCESS TO IDENTIFYING INFORMATION
To
ghts to
i
Your parental
r
have been terminated.
Nevertheless,
ou have the ability (i) to make medical
y
and personal information
about you known
o the adopting parents and/or your child;
t
nd (ii) to control
a
f and how your identifying
i
o the adopting parents and/
t
information
is disclosed
or your child.
Forms to provide medical
social history
r
o
, personal,
update
information,
such information,
horize or restrict
t
u
a
he release of identifying
t
formation,
n
i
or withdraw
to release
authorization
dentifying info
i
mation can be found online
r
at www.adoptpakids.org/Forms.aspx
or by calling
800-
227-0225.
These fom1s are provided free by PAIR (Pennsylvania
Adoption
Information
Registry,
Human Senrices
f
Department
o
); they should be completed and returned to PAIR.
You may also file this information
with the court using the same forms provided
by PAIR or providing
statement in your own words signed by you. Please make sure
a written
o include the case caption and docket number on your form or statement and send the documents
t
to:
You may update
information
this information
to either
as necessary
parent.
pertaining
biological
to reflect
a change in address
or any other
Form A-05 Rev. 7
/1/22
1
Your consent
to release
identifying
information
may be withdrawn
at any time by filing
a
withdrawal
of consent
form with PAIR and the court;
likewise,
you can change a
prior refusal
to
provide
identifying
information
by sending
and filing an authorization
to release.
Finally,
for information about
your name redacted
having
from your child's
birth
For assistance,
call 724-656-3100
or toll-free
1-844-228-3516.
For any additional
questions,
you can contact
PAIR, your Children
& Youth Social
Service
Agency,
any private
licensed
adoption
agency,
or the Orphans'
Court Division
of your
county's
Common Pleas Court.
visit
certificate,
please
https://www.health.pa.gov/topics/ce1iificates/Pages/
.
Adoptions.aspx
By: ___________
Orphans'
Clerk,
Court
_
Form A-05 Rev. 7/1/22
2
(Untitled)
This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts.
To learn more about the project, check out our about page.
Downloads: You can download both the original form (last checked 2023-03)
and the machine-processed form with normalized data fields.
About This Form:
- Sourced from www.pacourts.us (2023-03)
- Page(s): 2
- Fields(s): 8
- Average fields per page: 4
- Reading Level: Grade 11
- LIST Grouping(s):
FA-00-00-00-00.
Use our Rate My PDF tool to learn more.
Go beyond the above insights and learn more about this or any pdf form at
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Identified Data Fields:
We have done our best to automaticly identify and name form fields according to our naming conventions.
When possible, we've used names tied to our question library. See e.g., user1_name.
If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.
Here are the fields we could identify.
cour_f_commo_n_plea was COURT OF COMMON PLEAS OF (0.70 conf)to was To (0.43 conf)parental_rights was Your parental rights to (0.46 conf)unknown__1 was 1 (0.38 conf)unknown__2 was 2 (0.38 conf)1_2 was 1_2 (0.38 conf)2_2 was 2_2 (0.38 conf)by was By (0.38 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
cour_f_commo_n_pleatoparental_rightsunknown__1unknown__21_22_2
Suggested Screen 1:
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