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
:
Your parental rights to
have been
terminated.
Nevertheless, you have the ability (i) to make medical and personal information about you known
to the adopting parents and/or your child; and (ii) to control if and how your identifying
information is disclosed to the adopting parents and/or your child.
Forms to provide medical, personal, or social history information, update such information,
authorize or restrict the release of identifying information, or withdraw authorization to release
identifying information can be found online at www.adoptpakids.org/Forms.aspx or by calling 800-
227-0225. These forms are provided free by PAIR (Pennsylvania Adoption Information Registry,
Department of Human Services); 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 a written statement in your own words signed by you. Please make sure
to include the case caption and docket number on your form or statement and send the documents
to:
You may update this information as necessary to reflect a change in address or any other
information pertaining to either biological parent.
Form A-05 Rev. 7/1/22
1
By:
Clerk, Orphans’ Court
Your consent to release identifying information may be withdrawn at any time by filing a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 having your name redacted from your child's birth
certificate, please visit https://www.health.pa.gov/topics/certificates/Pages/Adoptions.aspx .
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.
Form A-05 Rev. 7/1/22
2
Adoptions
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): 5
- Average fields per page: 2
- Reading Level: Grade 16
- LIST Grouping(s):
Unknown
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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.
county was county (0.54 conf)af_f was AFF001 (0.51 conf)have_been was have__been (0.42 conf)may_update_information was you_may_update_this_information_as_necessary_to_reflect_a_change_in_address_or_any_other (0.30 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:
Suggested Screen 1:
af_fhave_beenmay_update_informationby
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