Form 67.28
	
Rule 67.28
	
APPLICATION FOR A PERMANENCE ORDER UNDER SECTION 80 OF THE ADOPTION AND CHILDREN (SCOTLAND) ACT 2007
	
UNTO THE RIGHT HONOURABLE THE LORDS OF COUNCIL AND SESSION
	
	Petition of
	
	[A.B.] ………………………………………………………………………………
(designation of local authority)
	
	……………………………………………………………………………………...
(insert full name of child as shown on birth certificate)
	
	who was born on …………………………………… (insert child’s date of birth)
	
	………………………………………………..…. (insert child’s present address)
	
	[or serial number where allocated]
	
	(insert the name(s) of the parent(s) or guardian(s)) ……………………………….

on the ground that …………………………………………………………………
	
	HUMBLY SHEWETH:
	
*delete as appropriate	1.	The child is (insert age of child) years of age, having been born on the ……………………….…. day of …………………………….
at ………………………………………….. (insert place of birth)
	
	2.	The child is *male/*female.
	
	3.	The child is not and never has been married or a civil partner.
	
	4.	The child’s natural mother is ………………………………………

……………………………………………………………………..
(insert full name and address)
	
	5.	The child’s natural father is ……….………………………………

……………………………………………………………………..
(insert full name and address)
	
	6.	The child’s natural father has*/does not have* parental responsibilities and rights.
	
	7.	*The child has the following guardians:

………………………………………………………………………
(insert name(s) and address(es))
	
	8.	*The child has been/is likely to be placed for adoption ……………
(give details).
	
	9.	*The child’s case was referred to the Children’s Hearing on

……………………….. (date).
	
	Arrangements for the child
	
	10.	*There is no person who has the right to have the child with him or otherwise to regulate the child’s residence under section 2(1)(a) of the Children (Scotland) Act 1995.
	
	11.	*The following person(s) have the right to have the child living with him/her/them or otherwise to regulate the child’s residence:

(insert name(s) of person(s))

but the child’s residence with that/those person(s) is likely to be seriously detrimental to the welfare of the child for the following reason(s) (give details).

	
	The following documents are lodged with this application:
	
	(i)	extract birth certificate in relation to the child;
	
	(ii)	*consent of [name and address] to the making of an adoption order;
	
	(iii)	*consent of the child dated ………………………………………..;
	
	(iv)	*local authority report dated ………………………………………
	
	The petitioner craves the court to make a permanence order under section 80 of the Adoption and Children (Scotland) Act 2007, in relation to the child including the mandatory provision
*and to include the following ancillary provisions (insert ancillary provisions sought in terms of section 82 of the Adoption and Children (Scotland) Act 2007)
*and to include that order provision granting authority for the child to be adopted
*and to dispense with the consent of ……………………………………………...	
		Signed …………………………………………….
[designation]

Date