IN THE COURT OF COMMON PLEAS OF 
 _____________________________ COUNTY, PENNSYLVANIA 
ORPHANS’ COURT DIVISION 

(FAMILY COURT DIVISION in Philadelphia County) 

IN RE: ADOPTION OF ______________ 

 (initials only) 

ADOPTION NO. ______________________ 

PRELIMINARY DECREE 

AND NOW, this   ______________  day of __________________, 20__, upon 

consideration of the within Petition and on the motion of _________________, 
Esquire, attorney for Petitioner(s) or______________________, Pro Se, a hearing 
thereon is fixed for ________________________________________________ in 
________________________ before the Honorable ________________________ 
at  __________ am/pm. 

Notice shall be given to the following persons and or entities having any legal 

and/or physical rights to the child:  

1.

NAME

ADDRESS

RELATIONSHIP  

2.

NAME

ADDRESS

RELATIONSHIP  

3.

NAME

ADDRESS

RELATIONSHIP  

Form A-11 Rev. 07/01/22

____________________________________ 
J.



Preliminary Decree

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