Pennsylvania Statutes Title 23 Pa.C.S.A. Domestic Relations § 2531. Report of intention to adopt

(1) The circumstances surrounding the persons receiving or retaining custody or physical care of the child, including the date upon which a preplacement investigation was concluded.

(2) The name, sex, racial background, age, date and place of birth and religious affiliation of the child.

(3) The name and address of the intermediary.

(4) An itemized accounting of moneys and consideration paid or to be paid to the intermediary.

(5) Whether the parent or parents whose parental rights are to be terminated have received counseling with respect to the termination and the alternatives thereto. If so, the report shall state the dates on which the counseling was provided and the name and address of the counselor or agency which provided the counseling.

(6) The name, address and signature of the person or persons making the report. Immediately above the signature of the person or persons intending to adopt the child shall appear the following statement:

I acknowledge that I have been advised or know and understand that the birth father or putative father may revoke the consent to the adoption of this child within 30 days after the later of the birth of the child or the date he has executed the consent to an adoption and that the birth mother may revoke the consent to an adoption of this child within 30 days after the date she has executed the consent.

(7) A copy of the preplacement report prepared pursuant to section 2530 (relating to home study and preplacement report).