Form 34D: Affidavit of Adoption of Applicant(s)

ONTARIO
Court File Number
(Name of Court)
at
Form 34D: Affidavit of
Adoption of Applicant(s),
sworn/affirmed
Court office address
Applicant(s) (The first letter of the applicant’s surname may be used)
Full legal name & address for service — street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).
Lawyer’s name & address — street & number, municipality, postal
code, telephone & fax numbers and e-mail address (if any).
Respondent(s) (If there is a respondent, the first letter of the respondent’s surname may be used)
Full legal name & address for service — street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).
Child
Lawyer’s name & address — street & number, municipality, postal
code, telephone & fax numbers and e-mail address (if any).
(Child’s full legal name. If this person is a Crown ward or was placed by a licensee or children’s aid society, you may use an initial for
the surname.)
Date of birth
Sex
Birth registration number
My/Our name is/are (full legal name(s))
I/We live in (municipality & province)
and I/we swear/affirm that the following is true:
1.
I am/We are the applicant(s) for the adoption of the child in this case and reside in Ontario.
2.
My/Our birthdate(s) is/are: (For two persons, indicate which birthdate belongs to whom.)
3.
The details of my/our background are as follows: (Give details of your health, education, employment, ability to support and care for
the child and any other relevant background material. If you need more space, you may add a page.)
Put a line through any blank space left on this page.
FLR-34D-E (2009/04)
Page 1 of 3
Form 34D:
4.
Affidavit of Adoption of Applicant(s)
(page 2)
Court File Number
The child is a resident of Ontario and is:
my/our grandchild by blood, marriage or adoption.
my/our grandnephew/grandniece by blood, marriage or adoption.
my/our nephew/niece by blood, marriage or adoption.
a child of my spouse.
a member of my/our band or native community.
not related to me/us.
5.
The history of my/our relationship with the child is as follows: (Give details of history of your relationship with the child. If you need
more space, you may add a page.)
Put a line through any blank space left on this page
FLR-34D-E (2009/04)
Page 2 of 3
Form 34D:
Affidavit of Adoption of Applicant(s)
(page 3)
Court File Number
Check applicable box.
6.
I am the sole applicant for this child's adoption and if an adoption order is made, I will be the child's only legal parent.
I am the sole applicant for this child’s adoption. If an adoption order is made, I will be joining with
,
(spouse’s full legal name)
who is my spouse within the meaning of Part VII of the Child and Family Services Act, and together, we will be the
child’s only legal parents.
We are applying for this child's adoption jointly as spouses within the meaning of Part VII of the Child and Family
Services Act. If an adoption order is made, we will be the child's only legal parents.
I/We understand and appreciate the special role of an adopting parent.
7.
8.
No payment or reward of any kind was made, given, received or agreed to be made, given or received by me/us or, to the
best of my/our knowledge, by any other person in connection with,
(a) the adoption of this child;
(b) this child’s placement for adoption;
(c) the giving of any consent to this child’s adoption; or
(d) any negotiations or arrangements leading up to this child’s adoption,
except for what is permitted by the Child and Family Services Act and the regulations made under that Act.
9.
I/We understand the importance of the child's culture and will make efforts to preserve his/her traditions, heritage and
cultural identity.
10. I/We understand that once the child turns eighteen years old, he/she can apply for a copy of his/her original birth
registration, if any, and a copy of his/her adoption order.
11. I/We understand that once the child turns nineteen years old, his/her birth parent(s) can apply for information from his/her
original birth registration, if any, any substituted birth registration, and his/her adoption order. This information would include
the child's full legal name after adoption.
12. I/We understand the provisions of the Vital Statistics Act and the Child and Family Services Act related to the disclosure of
adoption information
13. I/We want to bring to the court’s attention the following additional facts about the child’s best interests: (Give any additional
facts. If you need more space, you may add a page.)
Put a line through any blank space left on this page
Sworn/Affirmed before me at
in
municipality
province, state or country
on
Save Form
FLR-34D-E (2009/04)
date
Print Form
Commissioner for taking affidavits
(Type or print name below if signature is illegible.)
Signature
(This form is to be signed in front of a
lawyer, justice of the peace, notary public or
commissioner for taking affidavits.)
Clear Form
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