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. __________________ 

REPORT OF THE INTERMEDIARY IN THE ADOPTION OF A FOREIGN BORN CHILD 

The report of the agency, _______________________________________, as 
intermediary, under 23 Pa. C.S. § 2533, states as follows: 
1.

Intermediary's address:

2.

3.

4.

Intermediary’s telephone no:  
County where office is located:  

The facts as to the adoptee or adopted child are:
a) Name
b) Sex
c) Racial background
d) Age
e) Birth date
f) Birthplace
g) Religious affiliation
Date of the placement of the child with the Petitioner(s), adopting parent(s),

If known, the facts as to the birth mother are:
a) Name
b) Residence or last known address

c) Racial background
d) Age
e) Marital status as of the time of the birth of the child
f) Marital status during one year prior to birth of the child
g) Religious affiliation
h) Birth mother’s parental rights were terminated by decree of

dated 

Form A-10 Rev. 07/01/22

15.

If known, the facts as to the birth father are:
a) Name
b) Residence or last known address

c) Racial background
d) Age
e) Marital status as of the time of the birth of the child
f) Marital status during one year prior to birth of the child
g) Religious affiliation
h) Birth father’s parental rights were terminated by decree of

dated 

6.

All consents required by 23 Pa. C.S. § 2711 are attached to this Report as
exhibits or are not required for the following reasons, provide explanation:

7.

a) Attach a true and correct copy of the birth certificate or a registration of the
birth by the country of birth, with an English translation for those birth
certificates or registrations of birth not in English certified by a translator to be
true and correct.  If no birth certificate or other birth identification issued by the
country of birth can be obtained, a statement of the reason and a detailed
explanation of the efforts made to obtain the certificate are attached as exhibits
to this Report.

b) Attach copies of any foreign decrees and/or documents concerning this
adoption, including any decree terminating the parental rights of birth mother
and/or birth father, with an English translation for those decrees and/or
documents not in English, certified by a translator t be true and correct
translations of the decrees and/or documents.

Form A-10 Rev. 07/01/22

28.

9.

Attach a verified list of itemized fees and/or expenses paid or to be paid to or 
received by the intermediary and/or any other person or persons to the 
knowledge of the intermediary by reason of the adoption placement.

A full description and statement of the value of all property owned or 
possessed by the child, if any, is as follows: 

Form A-10 Rev. 07/01/22

310.

11.

No provision of any act regulating the interstate placement of children has
been violated with respect to the placement of the child.

The child’s medical history information was obtained and is available, except as
follows:

DATE:  

Form A-10 Rev. 07/01/22

Signature 

Print Name of signor

Title

Name of agency

4VERIFICATION TO REPORT OF INTERMEDIARY 

I,______________________________, 

verify 

that 

I 

am 

_______________________________________________ of _________________ 

(Title) 

_____________________________________________________________________ 
(Name of Agency) 

and I am authorized to take this verification on its behalf, and that the facts set forth in 

the foregoing Report are true and correct to the best of my knowledge, information and 

belief.  I further verify that all documents attached to this Report are true and correct 

copies of the originals.  I understand that false statements herein are made subject to 

the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.  

DATE: ____________________ 

_____________________________ 
Signature 

Form A-10 Rev. 07/01/22

5