Rule 7. | FORM 3. |
Statement in Support of Application for an Adoption Order [1]. |
In the High Court |
Mr. Justice |
In the Matter of A.B. [1] ...................................................................... an infant, and |
In the Matter of the Adoption Act. |
1. I, the undersigned, C.D./We, the undersigned, C.D. and F.D. desire to adopt A.B. [2], an infant, under the Adoption Act, 1953. |
2. I am/We are resident and domiciled in Saint Lucia. |
3. I am unmarried/a widow/widower/I am married to E.D. of ............................../We are married to each other and are the persons to whom the attached marriage certificate (or other evidence of marriage) relates. |
4. The infant is of the .............................. sex and unmarried. He/She was born on ................................................. and is the person to whom the attached birth certificate [3] relates/was born on or about the ......................................................... in ..................................[4]. |
5. The infant is the child/adopted child [3] of F.B. of ............................./whose last known address was ............................................................................../deceased and G.B. of ....................................................................../whose last known address was .........................................................../deceased [5]. |
6. The tutor of the infant is H.K. of ............................................................./The tutors of the infant are H.K. of .................................................................. and J.B. of ...............................................[6]. |
7. L.M. of ...................................... is liable by virtue of an order or agreement to contribute to the maintenance of the infant [7]. |
8. I/We attach a document/documents signifying the consent of the said ..................................................[8] to the making of an adoption order upon my/our application. |
9. I/We request the judge to dispense with the consent of the said .................................. [9] on the following grounds .................................................. |
10. The infant was received into my/our care and possession on the ....................................... 20..............., from ......................................................... of ....................................... and has been continuously in my/our care and possession since that date. |
11. A certificate as to physical and mental health of the infant signed by a registered medical practitioner on the ....................................... 20..........., is attached [10]. |
12. I/We have not received or agreed to receive, and no person has made or given or agreed to make or give to me/us, any payment or other reward in consideration of the adoption [except as follows: ............................................................................................................................... |
13. I have not made/neither of us has made a previous application for an adoption order in respect of the same or any other infant to any court [except an application made to the ........................... court at ................................................... on the ................................................... 20.........., which was dealt with as follows: ............................................................................................................................... ............................................................................................................................... |
14. For the purposes of my/our application reference may be made to N.O. of ....................................................................................[11] |
15. I/We desire that my/our identity should be kept confidential, and the serial number of this application is ......................................................[12] or [I/We do not desire that my/our identity should be kept confidential]. |
16. Further particulars of myself/ourselves are set out in the annex to this statement. |
17. If an adoption order is made in pursuance of my/our application, it is proposed that the infant should be known as |
Dated the .......... day of .............................. 20.......... |
.................................................................... |
.................................................................... |
(Usual Signature of applicant/ applicants). |
ANNEX TO FORM 3. |
Further Particulars of Applicant or Applicants |
Particulars of C.D. |
Name in full (Block capitals) ..................................................................................... |
Address ................................................................................................................. |
Occupation ............................................................................................................. |
Date of Birth ........................................................................................................... |
Relationship (if any) to the infant .............................................................................. |
Particulars of E.D. |
Name in full (Block capitals) ..................................................................................... |
Address ................................................................................................................. |
Occupation ............................................................................................................. |
Date of Birth ........................................................................................................... |
Relationship (if any) to the infant .............................................................................. |
Notes : | |
[1] This statement must be verified by affidavit, to which the statement, marriage certificate and other documents referred to in the statement should be exhibited. |
[2] Enter the first name [s] and surname as shown in the birth certificate referred to in paragraph 4, if available; otherwise enter name [s] and surname by which the infant was known before being placed for adoption. |
[3] If the infant, has previously been adopted, a certified copy of the entry in the Adopted Children Register should be attached, and not a certified copy of the original entry in the Registers of Birth; and the particulars given in paragraph 5 should relate to the parent or parents by adoption and not to the natural parent or parents. |
[4] Where a birth certificate is not attached, enter the place (including country) of birth if known. |
[5] If the infant is illegitimate, the father's name should not be given in this entry; but see paragraph 7. |
[6] This paragraph should be completed only if the infant has a tutor other than the father or mother of the infant. |
[7] If the infant is illegitimate, enter the name of any person known to the applicant who has been adjudged by an affiliation order to be the putative father of the infant or who has acknowledged himself to be the father of the infant and agreed to contribute to his or her maintenance. |
[8] The names to be entered here (or in the following paragraph) are those of the persons named in paragraphs 5, 6 and 7, and (where the application is made by one of 2 spouses alone) of the spouse of the applicant. |
[9] This paragraph should be completed with the name of any of the persons mentioned in the previous note who has not signified his or her consent. See Section 5 of the Act as to the grounds on which consent may be dispensed with. |
[10] This paragraph need not be completed if the applicant or either of the applicants is a “relative” of the infant as defined by section 2 of the Act. |
[11] This paragraph need not be completed if the applicant or either of the applicants is a “relative” of the infant as defined by section 2 of the Act. Where it is completed more than one referee may be named if desired. |
[12] If the applicant wishes his or her name to be kept 'confidential, insert serial number obtained in pursuance of rule 4 of the Adoption of Children (High Court) Rules. |