Bill Text: IL HB1698 | 2011-2012 | 97th General Assembly | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Amends the Adoption Act. Provides a form of waiver of parental rights to be used by a putative or legal father of a born or unborn child.
Spectrum: Partisan Bill (Democrat 12-0)
Status: (Passed) 2011-06-28 - Public Act . . . . . . . . . 97-0018 [HB1698 Detail]
Download: Illinois-2011-HB1698-Introduced.html
Bill Title: Amends the Adoption Act. Provides a form of waiver of parental rights to be used by a putative or legal father of a born or unborn child.
Spectrum: Partisan Bill (Democrat 12-0)
Status: (Passed) 2011-06-28 - Public Act . . . . . . . . . 97-0018 [HB1698 Detail]
Download: Illinois-2011-HB1698-Introduced.html
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1 | AN ACT concerning civil law.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Adoption Act is amended by changing Section | |||||||||||||||||||
5 | 10 as follows:
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6 | (750 ILCS 50/10) (from Ch. 40, par. 1512)
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7 | Sec. 10. Forms of consent and surrender; execution and
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8 | acknowledgment thereof. | |||||||||||||||||||
9 | A. The form of consent required for the
adoption of a born | |||||||||||||||||||
10 | child shall be substantially as follows:
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11 | FINAL AND IRREVOCABLE CONSENT TO ADOPTION
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12 | I, ...., (relationship, e.g., mother, father, relative, | |||||||||||||||||||
13 | guardian)
of ...., a ..male child, state:
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14 | That such child was born on .... at ....
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15 | That I reside at ...., County of .... and State of ....
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16 | That I am of the age of .... years.
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17 | That I hereby enter my appearance in this proceeding and | |||||||||||||||||||
18 | waive
service of summons on me.
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19 | That I hereby acknowledge that I have been provided with a | |||||||||||||||||||
20 | copy of the Birth Parent Rights and Responsibilities-Private | |||||||||||||||||||
21 | Form before signing this Consent and that I have had time to | |||||||||||||||||||
22 | read, or have had read to me, this Form. I understand that if I | |||||||||||||||||||
23 | do not receive any of the rights as described in this Form, it |
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1 | shall not constitute a basis to revoke this Final and | ||||||
2 | Irrevocable Consent. | ||||||
3 | That I do hereby consent and agree to the adoption of such | ||||||
4 | child.
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5 | That I wish to and understand that by signing this consent | ||||||
6 | I do
irrevocably and permanently give up all custody and other | ||||||
7 | parental
rights I have to such child.
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8 | That I understand such child will be placed for adoption | ||||||
9 | and that I
cannot under any circumstances, after signing this | ||||||
10 | document, change my
mind and revoke or cancel this consent or | ||||||
11 | obtain or recover custody or
any other rights over such child. | ||||||
12 | That I have read and understand the
above and I am signing it | ||||||
13 | as my free and voluntary act.
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14 | Dated (insert date).
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15 | .........................
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16 | If under Section 8 the consent of more than one person is | ||||||
17 | required,
then each such person shall execute a separate | ||||||
18 | consent.
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19 | A-1. (1) The form of the Final and Irrevocable Consent to | ||||||
20 | Adoption by a Specified Person or Persons: Non-DCFS Case set | ||||||
21 | forth in this subsection A-1 is to be used by legal parents | ||||||
22 | only. This form is not to be used in cases in which there is a | ||||||
23 | pending petition under Section 2-13 of the Juvenile Court Act | ||||||
24 | of 1987. | ||||||
25 | (2) The form of the Final and Irrevocable Consent to |
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1 | Adoption by a Specified Person or Persons in a non-DCFS case | ||||||
2 | shall have the caption of the proceeding in which it is to be | ||||||
3 | filed and shall be substantially as follows: | ||||||
4 | FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY | ||||||
5 | A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE | ||||||
6 | I, ...., (relationship, e.g., mother, father) of ...., a | ||||||
7 | ..male child, state: | ||||||
8 | 1. That such child was born on ...., at ....., City of ... | ||||||
9 | and State of .... | ||||||
10 | 2. That I reside at ...., County of .... and State of .... | ||||||
11 | 3. That I am of the age of .... years. | ||||||
12 | 4. That I hereby enter my appearance in this proceeding and | ||||||
13 | waive service of summons on me. | ||||||
14 | 5. That I hereby acknowledge that I have been provided a | ||||||
15 | copy of the Birth Parent Rights and Responsibilities-Private | ||||||
16 | Form before signing this Consent and that I have had time to | ||||||
17 | read, or have had read to me, this Form and that I understand | ||||||
18 | the Rights and Responsibilities described in this Form. I | ||||||
19 | understand that if I do not receive any of my rights as | ||||||
20 | described in said Form, it shall not constitute a basis to | ||||||
21 | revoke this Final and Irrevocable Consent to Adoption by a | ||||||
22 | Specified Person. | ||||||
23 | 6. That I do hereby consent and agree to the adoption of | ||||||
24 | such child by .... (specified persons) only. | ||||||
25 | 7. That I wish to and understand that upon signing this | ||||||
26 | consent I do irrevocably and permanently give up all custody |
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1 | and other parental rights I have to such child if such child is | ||||||
2 | adopted by .... (specified person or persons). I hereby | ||||||
3 | transfer all of my rights to the custody, care and control of | ||||||
4 | such child to ............................. (specified person | ||||||
5 | or persons). | ||||||
6 | 8. That I understand such child will be adopted by | ||||||
7 | ....................... (specified person or persons) and that | ||||||
8 | I cannot under any circumstances, after signing this document, | ||||||
9 | change my mind and revoke or cancel this consent or obtain or | ||||||
10 | recover custody or any other rights over such child if | ||||||
11 | ............................ (specified person or persons) | ||||||
12 | adopt(s) such child; PROVIDED that each specified person has | ||||||
13 | filed or shall file, within 60 days from the date hereof, a | ||||||
14 | petition for the adoption of such child. | ||||||
15 | 9. That if the specified person or persons designated | ||||||
16 | herein do not file a petition for adoption within the | ||||||
17 | time-frame specified above, or, if said petition for adoption | ||||||
18 | is filed within the time-frame specified above but the adoption | ||||||
19 | petition is dismissed with prejudice or the adoption proceeding | ||||||
20 | is otherwise concluded without an order declaring the child to | ||||||
21 | be the adopted child of the specified person or persons, then I | ||||||
22 | understand that I will receive written notice of such | ||||||
23 | circumstances within 10 business days of their occurrence. I | ||||||
24 | understand that the notice will be directed to me using the | ||||||
25 | contact information I have provided in this consent. I | ||||||
26 | understand that I will have 10 business days from the date that |
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1 | the written notice is sent to me to respond, within which time | ||||||
2 | I may request the Court to declare this consent voidable and | ||||||
3 | return the child to me. I further understand that the Court | ||||||
4 | will make the final decision of whether or not the child will | ||||||
5 | be returned to me. If I do not make such request within 10 | ||||||
6 | business days of the date of the notice, then I expressly waive | ||||||
7 | any other notice or service of process in any legal proceeding | ||||||
8 | for the adoption of the child. | ||||||
9 | 10. That I expressly acknowledge that nothing in this | ||||||
10 | Consent
impairs the validity and absolute finality of this
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11 | Consent under any circumstance other than those described in
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12 | paragraph 9 of this Consent. | ||||||
13 | 11. That I understand that I have a remaining duty and
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14 | obligation to keep .............. (insert name and address of | ||||||
15 | the attorney
for the specified person or persons) informed of | ||||||
16 | my current
address or other preferred contact information until | ||||||
17 | this adoption has been finalized. My failure to
do so may | ||||||
18 | result in the termination of my parental rights and
the child | ||||||
19 | being placed for adoption in another home. | ||||||
20 | 12. That I do expressly waive any other notice or service | ||||||
21 | of process in any of the legal proceedings for the adoption of | ||||||
22 | the child as long as the adoption proceeding by the specified | ||||||
23 | person or persons is pending. | ||||||
24 | 13. That I have read and understand the above and I am | ||||||
25 | signing it as my free and voluntary act. | ||||||
26 | 14. That I acknowledge that this consent is valid even if |
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1 | the specified person or persons separate or divorce or one of | ||||||
2 | the specified persons dies prior to the entry of the final | ||||||
3 | judgment for adoption. | ||||||
4 | Dated (insert date). | ||||||
5 | ............................................. | ||||||
6 | Signature of parent. | ||||||
7 | ............................................. | ||||||
8 | Address of parent. | ||||||
9 | ............................................. | ||||||
10 | Phone number(s) of parent. | ||||||
11 | ............................................. | ||||||
12 | Personal email(s) of parent. | ||||||
13 | ............................................. | ||||||
14 | (3) The form of the certificate of acknowledgement for a | ||||||
15 | Final and Irrevocable Consent for Adoption by a Specified | ||||||
16 | Person or Persons: Non-DCFS Case shall be substantially as | ||||||
17 | follows:
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18 | STATE OF ..............)
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19 | ) SS.
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20 | COUNTY OF .............) | ||||||
21 | I, .................... (Name of Judge or other person), | ||||||
22 | ..................... (official title, name, and address), | ||||||
23 | certify that ............., personally known to me to be the | ||||||
24 | same person whose name is subscribed to the foregoing Final and | ||||||
25 | Irrevocable Consent for Adoption by a Specified Person or |
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1 | Persons; non-DCFS case, appeared before me this day in person | ||||||
2 | and acknowledged that (she)(he) signed and delivered the | ||||||
3 | consent as (her)(his) free and voluntary act, for the specified | ||||||
4 | purpose. I am further satisfied that, before signing this | ||||||
5 | Consent, ........ has read, or has had read to him or her, the | ||||||
6 | Birth Parent Rights and Responsibilities-Private Form. | ||||||
7 | A-2. Birth Parent Rights and Responsibilities-Private | ||||||
8 | Form. The Birth Parent Rights and Responsibilities-Private | ||||||
9 | Form must be read by, or have been read to, any person | ||||||
10 | executing a Final and Irrevocable Consent to Adoption under | ||||||
11 | subsection A, a Final and Irrevocable Consent to Adoption by a | ||||||
12 | Specified Person or Persons: Non-DCFS Case under subsection | ||||||
13 | A-1, or a Consent to Adoption of Unborn Child under subsection | ||||||
14 | B prior to the execution of said Consent. The form of the Birth | ||||||
15 | Parent Rights and Responsibilities-Private Form shall be | ||||||
16 | substantially as follows: | ||||||
17 | Birth Parent Rights and Responsibilities-Private Form | ||||||
18 | As a birth parent in the State of Illinois, you have the | ||||||
19 | right: | ||||||
20 | 1. To have your own attorney represent you. The prospective | ||||||
21 | adoptive parents may agree to pay for the cost of your attorney | ||||||
22 | in a manner consistent with Illinois law, but they are not | ||||||
23 | required to do so. | ||||||
24 | 2. To be treated with dignity and respect at all times and | ||||||
25 | to make decisions free from coercion and pressure. | ||||||
26 | 3. To receive counseling before and after signing a Final |
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1 | and Irrevocable Consent to Adoption ("Consent"), a Final and | ||||||
2 | Irrevocable Consent to Adoption by a Specified Person or | ||||||
3 | Persons: Non-DCFS Case ("Specified Consent"), or a Consent to | ||||||
4 | Adoption of Unborn Child ("Unborn Consent"). The prospective | ||||||
5 | adoptive parents may agree to pay for the cost of counseling in | ||||||
6 | a manner consistent with Illinois law, but they are not | ||||||
7 | required to do so. | ||||||
8 | 4. To ask to be involved in choosing your child's | ||||||
9 | prospective adoptive parents and to ask to meet them. | ||||||
10 | 5. To ask your child's prospective adoptive parents any | ||||||
11 | questions that pertain to your decision to place your child | ||||||
12 | with them. | ||||||
13 | 6. To see your child before signing a Consent or Specified | ||||||
14 | Consent. | ||||||
15 | 7. To request contact with your child and/or the child's | ||||||
16 | prospective adoptive parents, with the understanding that any | ||||||
17 | promises regarding contact with your child or receipt of | ||||||
18 | information about the child after signing a Consent, Specified | ||||||
19 | Consent, or Unborn Consent cannot be enforced under Illinois | ||||||
20 | law. | ||||||
21 | 8. To receive copies of all documents that you sign and | ||||||
22 | have those documents provided to you in your preferred | ||||||
23 | language. | ||||||
24 | 9. To request that your identifying information remain | ||||||
25 | confidential, unless required otherwise by Illinois law or | ||||||
26 | court order, and to register with the Illinois Adoption |
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1 | Registry and Medical Information Exchange. | ||||||
2 | 10. To work with an adoption agency or attorney of your | ||||||
3 | choice, or change said agency or attorney, provided you | ||||||
4 | promptly inform all of the parties currently involved. | ||||||
5 | 11. To receive, upon request, a written list of any | ||||||
6 | promised support, financial or otherwise, from your attorney or | ||||||
7 | the attorney for your child's prospective adoptive parents. | ||||||
8 | 12. To delay signing a Consent, Specified Consent, or | ||||||
9 | Unborn Consent if you are not ready to do so. | ||||||
10 | 13. To decline to sign a Consent, Specified Consent, or | ||||||
11 | Unborn Consent even if you have received financial support from | ||||||
12 | the prospective adoptive parents. | ||||||
13 | If you do not receive any of the rights described in this | ||||||
14 | Form, it shall not be a basis to revoke a Consent, Specified | ||||||
15 | Consent, or Unborn Consent. | ||||||
16 | As a Birth Parent in the State of Illinois, you have the | ||||||
17 | responsibility: | ||||||
18 | 1. To carefully consider your reasons for choosing | ||||||
19 | adoption. | ||||||
20 | 2. To voluntarily provide all known medical, background, | ||||||
21 | and family information about yourself and your immediate family | ||||||
22 | to your child's prospective adoptive parents or their attorney. | ||||||
23 | For the health of your child, you are strongly encouraged, but | ||||||
24 | not required, to provide all known medical, background, and | ||||||
25 | family history information about yourself and your family to | ||||||
26 | your child's prospective adoptive parents or their attorney. |
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1 | 3. (Birth mothers only) To accurately complete an Affidavit | ||||||
2 | of Identification, which identifies the father of the child | ||||||
3 | when known, with the understanding that a birth mother has a | ||||||
4 | right to decline to identify the birth father. | ||||||
5 | 4. To not accept financial support or reimbursement of | ||||||
6 | pregnancy related expenses simultaneously from more than one | ||||||
7 | source. | ||||||
8 | B. The form of consent required for the adoption of an | ||||||
9 | unborn child
shall be substantially as follows:
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10 | CONSENT TO ADOPTION OF UNBORN CHILD
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11 | I, ...., state:
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12 | That I am the father of a child expected to be born on or | ||||||
13 | about ....
to .... (name of mother).
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14 | That I reside at .... County of ...., and State of .....
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15 | That I am of the age of .... years.
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16 | That I hereby enter my appearance in such adoption | ||||||
17 | proceeding and
waive service of summons on me.
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18 | That I hereby acknowledge that I have been provided with a | ||||||
19 | copy of the Birth Parent Rights and Responsibilities-Private | ||||||
20 | Form before signing this Consent, and that I have had time to | ||||||
21 | read, or have had read to me, this Form. I understand that if I | ||||||
22 | do not receive any of the rights as described in this Form, it | ||||||
23 | shall not constitute a basis to revoke this Consent to Adoption | ||||||
24 | of Unborn Child. | ||||||
25 | That I do hereby consent and agree to the adoption of such | ||||||
26 | child, and
that I have not previously executed a consent or |
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1 | surrender with respect
to such child.
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2 | That I wish to and do understand that by signing this | ||||||
3 | consent I do
irrevocably and permanently give up all custody | ||||||
4 | and other parental
rights I have to such child, except that I | ||||||
5 | have the right to revoke this
consent by giving written notice | ||||||
6 | of my revocation not later than 72
hours after the birth of the | ||||||
7 | child.
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8 | That I understand such child will be placed for adoption | ||||||
9 | and that,
except as hereinabove provided, I cannot under any | ||||||
10 | circumstances, after
signing this document, change my mind and | ||||||
11 | revoke or cancel this consent
or obtain or recover custody or | ||||||
12 | any other rights over such child.
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13 | That I have read and understand the above and I am signing | ||||||
14 | it as my
free and voluntary act.
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15 | Dated (insert date).
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16 | ........................
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17 | B-5. (1) The parent of a child may execute a consent to | ||||||
18 | standby
adoption by a specified person or persons. A consent | ||||||
19 | under this subsection B-5
shall be acknowledged by a parent | ||||||
20 | pursuant to subsection H and subsection K of
this Section.
The | ||||||
21 | form of consent required for the standby adoption of a born | ||||||
22 | child
effective at a future date when the consenting
parent of | ||||||
23 | the child dies or
requests that a final judgment of adoption be | ||||||
24 | entered shall be substantially as
follows:
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25 | FINAL AND IRREVOCABLE CONSENT
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26 | TO STANDBY ADOPTION
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1 | I, ..., (relationship, e.g. mother or father)
of ...., a | ||||||
2 | ..male child, state:
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3 | That the child was born on .... at .....
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4 | That I reside at ...., County of ...., and State of .....
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5 | That I am of the age of .... years.
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6 | That I hereby enter my appearance in this proceeding and | ||||||
7 | waive service of
summons on me in this action only.
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8 | That I do hereby consent and
agree to the standby adoption | ||||||
9 | of the child, and that I have not previously
executed a consent | ||||||
10 | or surrender with respect to the child.
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11 | That I wish to and understand that by signing this consent | ||||||
12 | I do irrevocably
and permanently give up all custody and other | ||||||
13 | parental rights I have to the
child, effective upon
(my death) | ||||||
14 | (the child's other parent's death) or upon (my) (the other
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15 | parent's) request for the entry of a final judgment for | ||||||
16 | adoption if .....
(specified person or persons) adopt my child.
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17 | That I understand that until (I die) (the child's other | ||||||
18 | parent dies), I
retain all legal rights and obligations | ||||||
19 | concerning the child, but at that time,
I irrevocably give all | ||||||
20 | custody and other parental rights to .... (specified
person or | ||||||
21 | persons).
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22 | I understand my child will be adopted by ....... (specified | ||||||
23 | person or
persons) only and that I cannot, under any | ||||||
24 | circumstances, after signing this
document, change my mind and | ||||||
25 | revoke or cancel this consent or obtain or recover
custody or | ||||||
26 | any other rights over my child if ..... (specified person or
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1 | persons) adopt my child.
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2 | I understand that this consent to standby adoption is valid | ||||||
3 | only if the
petition for standby adoption is filed and that if | ||||||
4 | ....... (specified person or
persons), for any reason, cannot | ||||||
5 | or will not file a petition for standby
adoption or if his, | ||||||
6 | her, or their petition for standby adoption is denied, then
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7 | this consent is void. I have the right to notice of any other | ||||||
8 | proceeding that
could affect my parental rights.
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9 | That I have read and understand the above and I am signing | ||||||
10 | it as my free and
voluntary act.
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11 | Dated (insert date).
| ||||||
12 | ....................
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13 | If under Section 8 the consent of more than one person is | ||||||
14 | required, then each
such
person shall execute a separate | ||||||
15 | consent. A separate consent shall be executed
for each
child.
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16 | (2) If the parent consents to a standby adoption by 2 | ||||||
17 | specified persons,
then the form shall contain 2 additional | ||||||
18 | paragraphs in substantially the
following form:
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19 | If .... (specified persons) obtain a judgment of
| ||||||
20 | dissolution of
marriage before the judgment for adoption is | ||||||
21 | entered, then .....
(specified person) shall adopt my child. I | ||||||
22 | understand that I cannot change my
mind and revoke this consent | ||||||
23 | or obtain or recover custody of my child if .....
(specified | ||||||
24 | persons) obtain a judgment of dissolution of marriage and .....
| ||||||
25 | (specified person) adopts my child. I understand that I cannot |
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1 | change my
mind and revoke this consent if ...... (specified | ||||||
2 | persons) obtain a
judgment of dissolution of marriage before | ||||||
3 | the adoption is final. I
understand that this consent to | ||||||
4 | adoption has no effect on who will get custody
of my child if | ||||||
5 | ..... (specified persons) obtain a judgment of dissolution
of | ||||||
6 | marriage after the adoption is final. I understand that if | ||||||
7 | either .....
(specified persons) dies before the petition to | ||||||
8 | adopt my child is granted, then
the surviving person may adopt | ||||||
9 | my child. I understand that I cannot change my
mind and revoke | ||||||
10 | this consent or obtain or recover custody of my child if the
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11 | surviving person adopts my child.
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12 | A consent to standby adoption by specified persons on this | ||||||
13 | form shall have no
effect on a court's determination of custody | ||||||
14 | or visitation under the Illinois
Marriage and Dissolution
of | ||||||
15 | Marriage Act if the marriage of the specified persons is | ||||||
16 | dissolved before
the adoption is final.
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17 | (3) The form of the certificate of acknowledgement for a | ||||||
18 | Final and
Irrevocable Consent for Standby Adoption shall be | ||||||
19 | substantially as follows:
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20 | STATE OF .....)
| ||||||
21 | ) SS.
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22 | COUNTY OF ....)
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23 | I, ....... (name of Judge or other person) ..... (official | ||||||
24 | title,
name, and address), certify that ......., personally |
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1 | known to me to be
the same person whose name is subscribed to | ||||||
2 | the foregoing Final and Irrevocable
Consent to Standby | ||||||
3 | Adoption, appeared before me this day in person and
| ||||||
4 | acknowledged that (she) (he) signed and
delivered the consent | ||||||
5 | as (her) (his) free and voluntary act, for the specified
| ||||||
6 | purpose.
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7 | I have fully explained that this consent to adoption is | ||||||
8 | valid only if the
petition to adopt is filed, and that if the | ||||||
9 | specified person or persons, for
any reason, cannot or will not | ||||||
10 | adopt the child or if the adoption petition is
denied, then | ||||||
11 | this consent will be void. I have fully explained that if the
| ||||||
12 | specified person or persons adopt the child, by signing this | ||||||
13 | consent (she) (he)
is irrevocably and permanently | ||||||
14 | relinquishing all parental rights to the child,
and (she) (he) | ||||||
15 | has stated that such is (her) (his) intention and desire.
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16 | Dated (insert date).
| ||||||
17 | Signature ..............................
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18 | (4) If a consent to standby adoption is executed in this | ||||||
19 | form,
the consent shall be valid only if the specified
person | ||||||
20 | or persons adopt the child. The consent shall be void if:
| ||||||
21 | (a) the specified person or persons do not file a petition | ||||||
22 | for standby
adoption of the child; or
| ||||||
23 | (b) a court denies the standby adoption petition.
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24 | The parent shall not need to take further action to revoke | ||||||
25 | the consent if the
standby adoption by the specified person or | ||||||
26 | persons does not occur,
notwithstanding the provisions of |
| |||||||
| |||||||
1 | Section 11 of this Act.
| ||||||
2 | C. The form of surrender to any agency given by a parent of | ||||||
3 | a born
child who is to be subsequently placed for adoption | ||||||
4 | shall be
substantially as follows and shall contain such other | ||||||
5 | facts and
statements as the particular agency shall require.
| ||||||
6 | FINAL AND IRREVOCABLE SURRENDER
| ||||||
7 | FOR PURPOSES OF ADOPTION
| ||||||
8 | I, .... (relationship, e.g., mother, father, relative, | ||||||
9 | guardian) of
...., a ..male child, state:
| ||||||
10 | That such child was born on ...., at .....
| ||||||
11 | That I reside at ...., County of ...., and State of .....
| ||||||
12 | That I am of the age of .... years.
| ||||||
13 | That I do hereby surrender and entrust the entire custody | ||||||
14 | and control
of such child to the .... (the "Agency"), a | ||||||
15 | (public) (licensed) child
welfare agency with its principal | ||||||
16 | office in the City of ...., County of
.... and State of ...., | ||||||
17 | for the purpose of enabling it to care for and
supervise the | ||||||
18 | care of such child, to place such child for adoption and
to | ||||||
19 | consent to the legal adoption of such child.
| ||||||
20 | That I hereby grant to the Agency full power and authority | ||||||
21 | to place
such child with any person or persons it may in its | ||||||
22 | sole discretion
select to become the adopting parent or parents | ||||||
23 | and to consent to the
legal adoption of such child by such | ||||||
24 | person or persons; and to take any
and all measures which, in | ||||||
25 | the judgment of the Agency, may be for the
best interests of | ||||||
26 | such child, including authorizing medical, surgical
and dental |
| |||||||
| |||||||
1 | care and treatment including inoculation and anaesthesia for
| ||||||
2 | such child.
| ||||||
3 | That I wish to and understand that by signing this | ||||||
4 | surrender I do
irrevocably and permanently give up all custody | ||||||
5 | and other parental
rights I have to such child.
| ||||||
6 | That I understand I cannot under any circumstances, after | ||||||
7 | signing
this surrender, change my mind and revoke or cancel | ||||||
8 | this surrender or
obtain or recover custody or any other rights | ||||||
9 | over such child.
| ||||||
10 | That I have read and understand the above and I am signing | ||||||
11 | it as my
free and voluntary act.
| ||||||
12 | Dated (insert date).
| ||||||
13 | ........................
| ||||||
14 | C-5. The form of a Final and Irrevocable Designated | ||||||
15 | Surrender for Purposes of Adoption to any agency given by a | ||||||
16 | parent of a born child who is to be subsequently placed for | ||||||
17 | adoption shall be substantially as follows and shall contain | ||||||
18 | such other facts and statements as the particular agency shall | ||||||
19 | require: | ||||||
20 | FINAL AND IRREVOCABLE DESIGNATED SURRENDER | ||||||
21 | FOR PURPOSES OF ADOPTION | ||||||
22 | I, .... (relationship, e.g., mother, father, relative, | ||||||
23 | guardian) of ...., a ..male child, state: | ||||||
24 | 1. That such child was born on ...., at ..... | ||||||
25 | 2. That I reside at ...., County of ...., and State of | ||||||
26 | ..... |
| |||||||
| |||||||
1 | 3. That I am of the age of .... years. | ||||||
2 | 4. That I do hereby surrender and entrust the entire | ||||||
3 | custody and control of such child to the .... (the "Agency"), a | ||||||
4 | (public) (licensed) child welfare agency with its principal | ||||||
5 | office in the City of ...., County of .... and State of ...., | ||||||
6 | for the purpose of enabling it to care for and supervise the | ||||||
7 | care of such child, to place such child for adoption with | ||||||
8 | ............................. (specified person or persons) | ||||||
9 | and to consent to the legal adoption of such child and to take | ||||||
10 | any and all measures which, in the judgment of the Agency, may | ||||||
11 | be for the best interests of such child, including authorizing | ||||||
12 | medical, surgical and dental care and treatment including | ||||||
13 | inoculation and anesthesia for such child. | ||||||
14 | 5. That I wish to and understand that by signing this | ||||||
15 | surrender I do irrevocably and permanently give up all custody | ||||||
16 | and other parental rights I have to such child. | ||||||
17 | 6. That if the petition for adoption is not filed by the
| ||||||
18 | specified person or persons designated herein or, if the
| ||||||
19 | petition for adoption is filed but the adoption petition is
| ||||||
20 | dismissed with prejudice or the adoption proceeding is
| ||||||
21 | otherwise concluded without an order declaring the child to be
| ||||||
22 | the adopted child of each specified person, then I understand | ||||||
23 | that the Agency will provide notice to me within 10 business | ||||||
24 | days and that such notice will be directed to me using the | ||||||
25 | contact information I have provided to the Agency. I understand | ||||||
26 | that I will have 10 business days from the date that the Agency |
| |||||||
| |||||||
1 | sends me its notice to respond, within which time I may choose | ||||||
2 | to designate other adoptive parent(s). However, I acknowledge | ||||||
3 | that
the Agency has full power and authority to place the child | ||||||
4 | for adoption with
any person or persons it may in its sole | ||||||
5 | discretion select to
become the adopting parent or parents and | ||||||
6 | to consent to the
legal adoption of the child by such person or | ||||||
7 | persons. | ||||||
8 | 7. That I acknowledge that this surrender is valid even if | ||||||
9 | the specified persons separate or divorce or one of the | ||||||
10 | specified persons dies prior to the entry of the final judgment | ||||||
11 | for adoption. | ||||||
12 | 8. That I expressly acknowledge that the above paragraphs 6 | ||||||
13 | and 7 do not impair the validity and absolute finality of this | ||||||
14 | surrender under any circumstance. | ||||||
15 | 9. That I understand that I have a remaining obligation to | ||||||
16 | keep the Agency informed of my current contact information | ||||||
17 | until the adoption of the child has been finalized if I wish to | ||||||
18 | be notified in the event the adoption by the specified | ||||||
19 | person(s) cannot proceed. | ||||||
20 | 10. That I understand I cannot under any circumstances, | ||||||
21 | after signing this surrender, change my mind and revoke or | ||||||
22 | cancel this surrender or obtain or recover custody or any other | ||||||
23 | rights over such child. | ||||||
24 | 11. That I have read and understand the above and I am | ||||||
25 | signing it as my free and voluntary act. | ||||||
26 | Dated (insert date). |
| |||||||
| |||||||
1 | .............................. | ||||||
2 | D. The form of surrender to an agency given by a parent of | ||||||
3 | an unborn
child who is to be subsequently placed for adoption | ||||||
4 | shall be
substantially as follows and shall contain such other | ||||||
5 | facts and
statements as the particular agency shall require.
| ||||||
6 | SURRENDER OF UNBORN CHILD FOR
| ||||||
7 | PURPOSES OF ADOPTION
| ||||||
8 | I, .... (father), state:
| ||||||
9 | That I am the father of a child expected to be born on or | ||||||
10 | about ....
to .... (name of mother).
| ||||||
11 | That I reside at ...., County of ...., and State of .....
| ||||||
12 | That I am of the age of .... years.
| ||||||
13 | That I do hereby surrender and entrust the entire custody | ||||||
14 | and control
of such child to the .... (the "Agency"), a | ||||||
15 | (public) (licensed) child
welfare agency with its principal | ||||||
16 | office in the City of ...., County of
.... and State of ...., | ||||||
17 | for the purpose of enabling it to care for and
supervise the | ||||||
18 | care of such child, to place such child for adoption and
to | ||||||
19 | consent to the legal adoption of such child, and that I have | ||||||
20 | not
previously executed a consent or surrender with respect to | ||||||
21 | such child.
| ||||||
22 | That I hereby grant to the Agency full power and authority | ||||||
23 | to place
such child with any person or persons it may in its | ||||||
24 | sole discretion
select to become the adopting parent or parents | ||||||
25 | and to consent to the
legal adoption of such child by such | ||||||
26 | person or persons; and to take any
and all measures which, in |
| |||||||
| |||||||
1 | the judgment of the Agency, may be for the
best interests of | ||||||
2 | such child, including authorizing medical, surgical
and dental | ||||||
3 | care and treatment, including inoculation and anaesthesia for
| ||||||
4 | such child.
| ||||||
5 | That I wish to and understand that by signing this | ||||||
6 | surrender I do
irrevocably and permanently give up all custody | ||||||
7 | and other parental
rights I have to such child.
| ||||||
8 | That I understand I cannot under any circumstances, after | ||||||
9 | signing
this surrender, change my mind and revoke or cancel | ||||||
10 | this surrender or
obtain or recover custody or any other rights | ||||||
11 | over such child, except
that I have the right to revoke this | ||||||
12 | surrender by giving written notice
of my revocation not later | ||||||
13 | than 72 hours after the birth of such child.
| ||||||
14 | That I have read and understand the above and I am signing | ||||||
15 | it as my
free and voluntary act.
| ||||||
16 | Dated (insert date).
| ||||||
17 | ........................
| ||||||
18 | E. The form of consent required from the parents for the | ||||||
19 | adoption of
an adult, when such adult elects to obtain such | ||||||
20 | consent, shall be
substantially as follows:
| ||||||
21 | CONSENT
| ||||||
22 | I, ...., (father) (mother) of ...., an adult, state:
| ||||||
23 | That I reside at ...., County of .... and State of .....
| ||||||
24 | That I do hereby consent and agree to the adoption of such | ||||||
25 | adult by
.... and .....
| ||||||
26 | Dated (insert date).
|
| |||||||
| |||||||
1 | .........................
| ||||||
2 | F. The form of consent required for the adoption of a child | ||||||
3 | of the
age of 14 years or upwards, or of an adult, to be given | ||||||
4 | by such person,
shall be substantially as follows:
| ||||||
5 | CONSENT
| ||||||
6 | I, ...., state:
| ||||||
7 | That I reside at ...., County of .... and State of ..... | ||||||
8 | That I am
of the age of .... years. That I consent and agree to | ||||||
9 | my adoption by
.... and .....
| ||||||
10 | Dated (insert date).
| ||||||
11 | ........................
| ||||||
12 | G. The form of consent given by an agency to the adoption | ||||||
13 | by
specified persons of a child previously surrendered to it | ||||||
14 | shall set
forth that the agency has the authority to execute | ||||||
15 | such consent. The
form of consent given by a guardian of the | ||||||
16 | person of a child sought to
be adopted, appointed by a court of | ||||||
17 | competent jurisdiction, shall set
forth the facts of such | ||||||
18 | appointment and the authority of the guardian to
execute such | ||||||
19 | consent.
| ||||||
20 | H. A consent (other than that given by an agency, or | ||||||
21 | guardian of the
person of the child sought to be adopted who | ||||||
22 | was appointed by a court of
competent jurisdiction) shall be | ||||||
23 | acknowledged by a parent before a judge of a court of competent | ||||||
24 | jurisdiction or, except as otherwise provided in
this Act, | ||||||
25 | before a representative of an agency, or before a person, other | ||||||
26 | than the attorney for the prospective adoptive parent or |
| |||||||
| |||||||
1 | parents, designated by a court of competent
jurisdiction.
| ||||||
2 | I. A surrender, or any other document equivalent to a | ||||||
3 | surrender, by
which a child is surrendered to an agency shall | ||||||
4 | be acknowledged by the
person signing such surrender, or other | ||||||
5 | document, before a judge of a court of competent jurisdiction, | ||||||
6 | or, except as otherwise provided in this Act, before a | ||||||
7 | representative of an agency, or before a person designated by a | ||||||
8 | court
of competent jurisdiction.
| ||||||
9 | J. The form of the certificate of acknowledgment for a | ||||||
10 | consent, a
surrender, or any other document equivalent to a | ||||||
11 | surrender, shall be
substantially as follows:
| ||||||
12 | STATE OF ....)
| ||||||
13 | ) SS.
| ||||||
14 | COUNTY OF ...)
| ||||||
15 | I, .... (Name of judge or other person), .... (official | ||||||
16 | title, name and
location of court or status or position of | ||||||
17 | other person),
certify that ...., personally known to me to be | ||||||
18 | the same person whose
name is subscribed to the foregoing | ||||||
19 | (consent) (surrender), appeared
before me this day in person | ||||||
20 | and acknowledged that (she) (he) signed and
delivered such | ||||||
21 | (consent) (surrender) as (her) (his) free and voluntary
act, | ||||||
22 | for the specified purpose.
| ||||||
23 | I have fully explained that by signing such (consent) | ||||||
24 | (surrender)
(she) (he) is irrevocably relinquishing all | ||||||
25 | parental rights to such
child or adult and (she) (he) has | ||||||
26 | stated that such is (her) (his)
intention and desire. (Add if |
| |||||||
| |||||||
1 | Consent only) I am further satisfied that, before signing this | ||||||
2 | Consent, ........ has read, or has had read to him or her, the | ||||||
3 | Birth Parent Rights and Responsibilities-Private Form.
| ||||||
4 | Dated (insert date).
| ||||||
5 | Signature ...............
| ||||||
6 | K. When the execution of a consent or a surrender is | ||||||
7 | acknowledged
before someone other than a judge,
such other | ||||||
8 | person shall have his or her signature on the certificate
| ||||||
9 | acknowledged before a notary public, in form substantially as | ||||||
10 | follows:
| ||||||
11 | STATE OF ....)
| ||||||
12 | ) SS.
| ||||||
13 | COUNTY OF ...)
| ||||||
14 | I, a Notary Public, in and for the County of ......, in the | ||||||
15 | State of
......, certify that ...., personally known to me to | ||||||
16 | be the
same person whose name is subscribed to the foregoing | ||||||
17 | certificate of
acknowledgment, appeared before me in person and | ||||||
18 | acknowledged that (she)
(he) signed such certificate as (her) | ||||||
19 | (his) free and voluntary act and
that the statements made in | ||||||
20 | the certificate are true.
| ||||||
21 | Dated (insert date).
| ||||||
22 | Signature ...................... Notary Public
| ||||||
23 | (official seal)
| ||||||
24 | There shall be attached a certificate of magistracy, or | ||||||
25 | other
comparable proof of office of the notary public |
| |||||||
| |||||||
1 | satisfactory to the
court, to a consent signed and acknowledged | ||||||
2 | in another state.
| ||||||
3 | L. A surrender or consent executed and acknowledged outside | ||||||
4 | of this
State, either in accordance with the law of this State | ||||||
5 | or in accordance
with the law of the place where executed, is | ||||||
6 | valid.
| ||||||
7 | M. Where a consent or a surrender is signed in a foreign | ||||||
8 | country,
the execution of such consent shall be acknowledged or | ||||||
9 | affirmed in a
manner conformable to the law and procedure of | ||||||
10 | such country.
| ||||||
11 | N. If the person signing a consent or surrender is in the | ||||||
12 | military
service of the United States, the execution of such | ||||||
13 | consent or surrender
may be acknowledged before a commissioned | ||||||
14 | officer and the signature of
such officer on such certificate | ||||||
15 | shall be verified or acknowledged
before a notary public or by | ||||||
16 | such other procedure as is then in effect
for such division or | ||||||
17 | branch of the armed forces.
| ||||||
18 | O. (1) The parent or parents of a child in whose interests | ||||||
19 | a petition
under Section 2-13 of the Juvenile Court Act of 1987 | ||||||
20 | is pending may, with the
approval of the designated | ||||||
21 | representative of the Department of Children and
Family | ||||||
22 | Services, execute a consent to adoption by a specified person | ||||||
23 | or
persons:
| ||||||
24 | (a) in whose physical custody the child has resided for | ||||||
25 | at least 6
months;
or
| ||||||
26 | (b) in whose physical custody at least one sibling of |
| |||||||
| |||||||
1 | the child who is the
subject of this consent has resided | ||||||
2 | for at least 6 months, and
the child who is
the subject of | ||||||
3 | this consent is currently residing in this foster home; or
| ||||||
4 | (c) in whose physical custody a child under one year of | ||||||
5 | age has resided
for at least 3 months.
| ||||||
6 | A consent under this subsection O shall be acknowledged by a | ||||||
7 | parent pursuant to
subsection H and subsection K of this | ||||||
8 | Section.
| ||||||
9 | (2) The consent to adoption by a specified person or | ||||||
10 | persons shall have the
caption of the proceeding in which it is | ||||||
11 | to be filed and shall be substantially
as follows:
| ||||||
12 | FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
| ||||||
13 | A SPECIFIED PERSON OR PERSONS: DCFS CASE
| ||||||
14 | I, ......................................, the | ||||||
15 | .................. (mother or
father) of a ....male child, | ||||||
16 | state:
| ||||||
17 | My child ............................ (name of child) | ||||||
18 | was born on
(insert date) at .................... Hospital | ||||||
19 | in
................ County, State of ...............
| ||||||
20 | I reside at ......................, County of | ||||||
21 | ............. and
State of ..............
| ||||||
22 | I, ..........................., am .... years old.
| ||||||
23 | I enter my appearance in this action to adopt my child | ||||||
24 | by the
person or persons specified herein by me and waive | ||||||
25 | service of
summons on me in this action only.
| ||||||
26 | I consent to the adoption of my child by
|
| |||||||
| |||||||
1 | .............................
(specified person or | ||||||
2 | persons) only.
| ||||||
3 | I wish to sign this consent and I understand that by | ||||||
4 | signing this
consent I irrevocably and permanently give up | ||||||
5 | all parental rights I have to my
child if my child is | ||||||
6 | adopted by ............................. (specified person
| ||||||
7 | or persons).
| ||||||
8 | I understand my child will be adopted by | ||||||
9 | .............................
(specified person or | ||||||
10 | persons) only and that I cannot under any circumstances,
| ||||||
11 | after signing this document, change my mind and revoke or | ||||||
12 | cancel this consent
or obtain or recover custody or any | ||||||
13 | other rights over my child if
............................ | ||||||
14 | (specified person or persons) adopt my child.
| ||||||
15 | I understand that this consent to adoption is valid | ||||||
16 | only if the
petition to adopt is filed within one year from | ||||||
17 | the date that I sign it and
that if ....................... | ||||||
18 | (specified person or persons), for any reason,
cannot or | ||||||
19 | will not file a petition to adopt my child within that one | ||||||
20 | year
period or if their adoption petition is denied, then | ||||||
21 | this consent will be
voidable after one year upon the | ||||||
22 | timely filing of my motion. If I file this
motion before | ||||||
23 | the filing of the petition for adoption, I understand that | ||||||
24 | the
court shall revoke this specific consent.
I have the | ||||||
25 | right to notice of any other proceeding that could affect | ||||||
26 | my
parental rights, except for the proceeding for |
| |||||||
| |||||||
1 | ............. (specified person
or persons) to adopt my | ||||||
2 | child.
| ||||||
3 | I have read and understand the above and I am signing | ||||||
4 | it as my free
and voluntary act.
| ||||||
5 | Dated (insert date).
| ||||||
6 | .............................................
| ||||||
7 | Signature of parent
| ||||||
8 | (3) If the parent consents to an adoption by 2 specified | ||||||
9 | persons, then the
form shall contain 2 additional paragraphs in | ||||||
10 | substantially the following form:
| ||||||
11 | If ............... (specified persons) get a divorce
| ||||||
12 | before the petition to adopt my child is granted, then | ||||||
13 | ..........
(specified person) shall adopt my child. I | ||||||
14 | understand that I
cannot change my mind and revoke this | ||||||
15 | consent or obtain or
recover custody over my child if | ||||||
16 | ............. (specified persons)
divorce and | ||||||
17 | ............. (specified person) adopts my
child. I | ||||||
18 | understand that I cannot change my mind and revoke
this | ||||||
19 | consent or obtain or recover custody over my child if
| ||||||
20 | ................. (specified persons) divorce after the
| ||||||
21 | adoption is final. I understand that this consent to | ||||||
22 | adoption
has no effect on who will get custody of my child | ||||||
23 | if they
divorce after the adoption is final.
| ||||||
24 | I understand that if either ...............
| ||||||
25 | (specified persons) dies before the petition to adopt
my | ||||||
26 | child is granted, then the surviving person can adopt my |
| |||||||
| |||||||
1 | child. I
understand that I cannot change my mind and revoke | ||||||
2 | this consent
or obtain or recover custody over my child if | ||||||
3 | the surviving
person adopts my child.
| ||||||
4 | A consent to adoption by specified persons on this form | ||||||
5 | shall
have no effect on a court's determination of custody or | ||||||
6 | visitation
under the Illinois Marriage and Dissolution of | ||||||
7 | Marriage Act if the
marriage of the
specified persons is | ||||||
8 | dissolved after the adoption is final.
| ||||||
9 | (4) The form of the certificate of acknowledgement for a | ||||||
10 | Final and
Irrevocable Consent for Adoption by a Specified | ||||||
11 | Person or Persons: DCFS Case shall be
substantially as follows:
| ||||||
12 | STATE OF ..............)
| ||||||
13 | ) SS.
| ||||||
14 | COUNTY OF .............)
| ||||||
15 | I, .................... (Name of Judge or other person),
| ||||||
16 | ..................... (official title, name, and address),
| ||||||
17 | certify that ............., personally known to me to be the | ||||||
18 | same person whose
name is subscribed to the foregoing Final and | ||||||
19 | Irrevocable Consent for Adoption
by a Specified Person or | ||||||
20 | Persons, appeared before me this day
in person and acknowledged | ||||||
21 | that (she)(he) signed and delivered the consent as
(her)(his) | ||||||
22 | free and voluntary act, for the specified purpose.
| ||||||
23 | I have fully explained that this consent to adoption is | ||||||
24 | valid only if the
petition to adopt is filed within one year |
| |||||||
| |||||||
1 | from the date that it is signed, and
that if the specified | ||||||
2 | person or persons, for any reason, cannot or will not
adopt the | ||||||
3 | child or if the adoption petition is denied, then this consent | ||||||
4 | will
be voidable after one year upon the timely filing of a | ||||||
5 | motion by the parent
to revoke the consent. I explained that if | ||||||
6 | this motion is filed before the
filing of the petition for | ||||||
7 | adoption, the court shall revoke this specific
consent. I have | ||||||
8 | fully explained that if the specified person or
persons adopt
| ||||||
9 | the child, by signing this consent this parent is irrevocably
| ||||||
10 | and permanently
relinquishing all parental rights to the child, | ||||||
11 | and this parent has stated that
such is (her)(his) intention | ||||||
12 | and desire.
| ||||||
13 | Dated (insert date).
| ||||||
14 | ...............................
| ||||||
15 | Signature
| ||||||
16 | (5) If a consent to adoption by a specified person or | ||||||
17 | persons is executed in
this form, the following provisions | ||||||
18 | shall apply. The consent shall be valid
only if that specified | ||||||
19 | person or persons adopt the child. The consent shall be
| ||||||
20 | voidable after one year if:
| ||||||
21 | (a) the specified person or persons do not file a | ||||||
22 | petition to adopt the
child within one year after the | ||||||
23 | consent is signed and the parent files a
timely motion to | ||||||
24 | revoke this consent. If this motion is filed before the
| ||||||
25 | filing of the petition for adoption the court shall revoke | ||||||
26 | this consent; or
|
| |||||||
| |||||||
1 | (b) a court denies the adoption petition; or
| ||||||
2 | (c) the Department of Children and Family Services | ||||||
3 | Guardianship
Administrator determines that the specified | ||||||
4 | person or persons will not or
cannot complete the adoption, | ||||||
5 | or in the best interests of the child should not
adopt the | ||||||
6 | child.
| ||||||
7 | Within 30 days of the consent becoming void, the Department | ||||||
8 | of Children and
Family Services Guardianship Administrator | ||||||
9 | shall make good faith attempts to
notify the parent in writing | ||||||
10 | and shall give written notice to the court and all
additional | ||||||
11 | parties in writing that the adoption has not occurred or will | ||||||
12 | not
occur and that the consent is void. If the adoption by a | ||||||
13 | specified person or
persons does not occur, no proceeding for | ||||||
14 | termination of parental rights shall
be brought unless the | ||||||
15 | biological parent who executed the consent to adoption by
a | ||||||
16 | specified person or persons has been notified of the proceeding | ||||||
17 | pursuant to
Section 7 of this Act or subsection (4) of Section | ||||||
18 | 2-13 of the Juvenile Court
Act of 1987. The parent shall not | ||||||
19 | need to take further action to revoke the
consent if the | ||||||
20 | specified adoption does not occur, notwithstanding the
| ||||||
21 | provisions of Section 11 of this Act.
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22 | (6) The Department of Children and Family Services is | ||||||
23 | authorized
to promulgate rules necessary to implement this | ||||||
24 | subsection O.
| ||||||
25 | (7) The Department shall collect and maintain data | ||||||
26 | concerning the efficacy
of specific consents. This data shall |
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1 | include the number of specific consents
executed and their | ||||||
2 | outcomes, including but not limited to the number of
children | ||||||
3 | adopted pursuant to the consents, the number of children for | ||||||
4 | whom
adoptions are not completed, and the reason or reasons why | ||||||
5 | the adoptions are
not completed.
| ||||||
6 | P. If the person signing a consent is incarcerated or | ||||||
7 | detained in a correctional facility, prison, jail, detention | ||||||
8 | center, or other comparable institution, either in this State | ||||||
9 | or any other jurisdiction, the execution of such consent may be | ||||||
10 | acknowledged before social service personnel of such | ||||||
11 | institution, or before a person designated by a court of | ||||||
12 | competent jurisdiction. | ||||||
13 | Q. A consent may be acknowledged telephonically, via | ||||||
14 | audiovisual connection, or other electronic means, provided | ||||||
15 | that a court of competent jurisdiction has entered an order | ||||||
16 | approving the execution of the consent in such manner and has | ||||||
17 | designated an individual to be physically present with the | ||||||
18 | parent executing such consent in order to verify the identity | ||||||
19 | of the parent. | ||||||
20 | R. An agency whose representative is acknowledging a | ||||||
21 | consent pursuant to this Section shall be a public child | ||||||
22 | welfare agency, or a child welfare agency, or a child placing | ||||||
23 | agency that is authorized or licensed in the State or | ||||||
24 | jurisdiction in which the consent is signed. | ||||||
25 | S. The form of waiver by a putative or legal father of a | ||||||
26 | born or unborn child shall be substantially as follows:
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1 | FINAL AND IRREVOCABLE | ||||||
2 | WAIVER OF PARENTAL RIGHTS OF PUTATIVE OR LEGAL FATHER | ||||||
3 | I, .................... , state under oath or affirm as | ||||||
4 | follows: | ||||||
5 | 1. That the biological mother ............... has | ||||||
6 | named me as a possible biological or
legal father of her | ||||||
7 | minor child who was born, or is expected to be born on
| ||||||
8 | ..........., ....... in City/Town .......... of State of | ||||||
9 | ........... | ||||||
10 | 2. That I understand that the biological mother | ||||||
11 | ............. intends to or has placed the child
for | ||||||
12 | adoption. | ||||||
13 | 3. That I reside at ................. in the City/Town | ||||||
14 | ............
of State of ................ | ||||||
15 | 4. That I am ................ years of age and my date | ||||||
16 | of birth is ..............., ............. | ||||||
17 | 5. That I (select one): | ||||||
18 | ..... am married to the biological mother. | ||||||
19 | ..... am not married to the biological mother and | ||||||
20 | have not been married to the biological
mother within | ||||||
21 | 300 days before the child's birth or expected date of | ||||||
22 | child's birth. | ||||||
23 | ..... am not currently married to the biological | ||||||
24 | mother, but was married to the biological
mother, |
| |||||||
| |||||||
1 | within 300 days before the child's birth or expected | ||||||
2 | date of child's birth. | ||||||
3 | 6. That I (select one) | ||||||
4 | ..... neither admit nor deny that I am the | ||||||
5 | biological father of the child. | ||||||
6 | ..... deny that I am the biological father of the | ||||||
7 | child. | ||||||
8 | 7. That I hereby agree to the termination of my | ||||||
9 | parental rights, if any, without further notice to me
of | ||||||
10 | any proceeding for the adoption of the minor child, even if | ||||||
11 | I have taken any action to establish
parental rights or | ||||||
12 | take any such action in the future including registering | ||||||
13 | with any putative father
registry. | ||||||
14 | 8. That I understand that by signing this Waiver I do | ||||||
15 | irrevocably and permanently give up all
custody and other | ||||||
16 | parental rights I may have to such child. | ||||||
17 | 9. That I understand that this Waiver is FINAL AND | ||||||
18 | IRREVOCABLE and that I am permanently
barred from | ||||||
19 | contesting any proceeding for the adoption of the child | ||||||
20 | after I sign this Waiver. | ||||||
21 | 10. That I waive any further service of summons or | ||||||
22 | other pleadings in any proceeding to terminate
parental | ||||||
23 | rights, if any to this child, or any proceeding for | ||||||
24 | adoption of this child. | ||||||
25 | 11. That I understand that if a final judgment or order | ||||||
26 | of adoption for this child is not entered, then
any |
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| |||||||
1 | parental rights or responsibilities that I may have remain | ||||||
2 | intact. | ||||||
3 | 12. That I have read and understand the above and that | ||||||
4 | I am signing it as my free and voluntary act.
| ||||||
5 | Dated: ................... , .............. | ||||||
6 | ........................................... | ||||||
7 | Signature
| ||||||
8 | OATH | ||||||
9 | I have been duly sworn and I state under oath that I have read | ||||||
10 | and understood this Final and Irrevocable
Waiver of Parental | ||||||
11 | Rights of Putative or Legal Father. The facts contained in it | ||||||
12 | are true and correct to the
best of my knowledge. I have signed | ||||||
13 | this document as my free and voluntary act in order to | ||||||
14 | facilitate the
adoption of the child.
| ||||||
15 | .............................. | ||||||
16 | Signature
| ||||||
17 | Signed and Sworn before me on | ||||||
18 | this ............ day | ||||||
19 | of ............ 20....
| ||||||
20 | ................... | ||||||
21 | Notary Public |
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1 | (Source: P.A. 96-601, eff. 8-21-09; 96-1461, eff. 1-1-11.)
|