This form contains 12 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Case Information
County Text
Provide the name of the county.
Docket or File Number Text
Provide the docket or file number for this case.
Child Information
Child's Full Name Text
Please provide the child's full name as it appears on their birth certificate, including First, Middle, Last, and Suffix.
Date of Birth Date
Please provide the child's date of birth.
Birthplace Text
Please provide the city and county of the child's birthplace.
Court Clerical Information
Text3 Text
This is an unlabeled text field. Refer to any accompanying instructions on the form to determine what information should be entered here.
Text4 Text
This is an unlabeled text field. Please enter the appropriate information as indicated by the form instructions.
Date Signed
Date Signed Date
Provide the date the petition was signed.
Father's/Parent's Name
Father's/Parent's First Name Prior to First Marriage Text
Please provide the father's or parent's first name as it appeared or was alleged prior to their first marriage.
Mother's/Parent's Name
Mother's/Parent's Prior Marriage Name Text
Please provide the mother's or parent's full name as it appeared prior to their first marriage, if applicable.
Name of Persons for Rights Termination
Name of Person Text
Enter the full name of the person whose parental rights are sought to be terminated.
Petition Filing Date and Time
Petition Filing Date and Time Date
Please enter the date and time when the petition was filed.