Adoption Consent Form

ARKANSAS PARENT CONSENT TO A PARTICULAR ADOPTION

This packet is for one parent whose written consent is required for a particular
minor-child adoption. It is not a private contract, does not itself grant an
adoption, and must not be converted into a parental-rights relinquishment,
agency surrender, contested termination, or adult-adoption form.

1. ATTORNEY USE GATES

• ☐ The child has been born. Ark. Code Ann. § 9-9-208(a) does not permit this
  consent to be executed before birth.

• ☐ Arkansas adoption counsel has determined that this parent's consent is
  required and has separately addressed every other required consent, notice,
  parentage, custody, agency, and court finding.

• ☐ The prospective adoptive parent or parents are identified. This is consent
  to a particular adoption, not a blank consent.

• ☐ Counsel has determined whether the Indian Child Welfare Act, the Interstate
  Compact on the Placement of Children, an existing juvenile case, or another
  special procedure applies.

• ☐ This matter does not require a separate relinquishment under Ark. Code Ann.
  § 9-9-220 or a contested proceeding in place of consent.

• ☐ No payment, benefit, promise, or expense reimbursement is being exchanged
  for the parent's consent or relinquishment.

• ☐ The independent-counsel and language-access sections below are complete.

• ☐ The correct clerk address and withdrawal-period election appear in the
  signed instrument.

Attorney confirming gates: [________________________________]

Arkansas Bar number: [________________]

Date confirmed: [__/__/____]

2. COURT AND FILING INFORMATION

Counsel must identify the court and county from the actual adoption or related
guardianship proceeding. Do not insert a generic “Family Division” label.

Ark. Code Ann. § 9-9-209 requires the consent to provide the address of the
probate division clerk for the county where the guardianship petition will be
filed, if there is a guardianship, or where the adoption petition will be
filed, if there is no guardianship.

Clerk: Probate Division Clerk of the Circuit Court

Required clerk address: [________________________________]

[________________________________]

3. CHILD, PARENT, AND PROPOSED ADOPTIVE PARENT INFORMATION

3.1 Child

3.2 Consenting Parent

3.3 Proposed Adoptive Parent or Parents

4. REQUIRED-CONSENT DETERMINATION

The 2025 amendment to Ark. Code Ann. § 9-9-206 changed the treatment of a
minor's consent: a minor who is twelve or older gives or affirms consent at the
adoption hearing, and the court may waive it only on the statutory finding.
Do not place the child's consent in this parent-signature instrument.

This parent's consent is required because:

[____________________________________________________________]

[____________________________________________________________]

Counsel's citation and analysis: [________________________________]

• ☐ Every other person or entity whose consent may be required has been listed
  in the adoption file.

• ☐ Any claimed exception to required consent will be decided through the
  proper court procedure and is not treated as established by this form.

• ☐ Any child-consent issue will be handled at the adoption hearing under the
  current version of § 9-9-206(b).

5. INDEPENDENT COUNSEL AND LANGUAGE ACCESS

5.1 Limited Independent Representation

Ark. Code Ann. § 9-9-208(d) generally gives a parent whose consent is required
limited, independent representation for executing the consent and, if elected,
withdrawing it. The independent attorney may not represent another party in the
adoption. Act 713 of 2025 changed the relative exception in § 9-9-208(d)(3)
from the second to the third degree.

Select one:

• ☐ The parent is represented by the independent attorney who will complete
  Section 9.

• ☐ The parent knowingly elects not to use independent counsel and will sign
  the sworn statutory waiver in Section 10 before a notary public.

• ☐ Section 9-9-208(d) does not apply because the petitioner is a stepparent
  whose spouse is a natural or adoptive parent of the child.

• ☐ Section 9-9-208(d) does not apply because the petitioner is related to the
  child within the third degree as defined in Ark. Code Ann. § 28-9-212.

• ☐ Section 9-9-208(d) does not apply because the petitioner is represented by
  an attorney pro bono in the adoption proceeding.

Petitioner will pay for offered limited representation: ☐ Yes

5.2 Qualified Interpreter

If the parent does not speak English as a native language, § 9-9-208(e)
generally requires a qualified interpreter from the Administrative Office of
the Courts' current registry, paid by the petitioner, before execution. Its
relative exception remains worded as “within the second degree.” Counsel must
not substitute the amended third-degree counsel exception for this separate
language-access text.

Select one:

• ☐ The parent speaks English as a native language; no § 9-9-208(e) interpreter
  is required.

• ☐ A qualified interpreter will interpret the consent and complete Section 11.

• ☐ The parent will sign the sworn interpreter waiver in Section 12, and that
  affidavit will be translated and filed as the statute requires.

• ☐ Counsel has documented a statutory exception to § 9-9-208(e):
  [________________________________].

6. PARENT'S CONSENT

I, [CONSENTING PARENT NAME], state and acknowledge as follows:

1. I am the [LEGAL RELATIONSHIP] of [CHILD NAME], who was born on
   [DATE] at [TIME]. I am signing after the child's birth.

2. I specifically and voluntarily consent to the adoption of the child by
   [PROPOSED ADOPTIVE PARENT NAME OR NAMES].

3. I understand that this one-parent consent does not establish that every
   required consent, notice, parentage issue, placement requirement, or court
   finding has been satisfied.

4. I have disclosed any existing custody, guardianship, juvenile, support,
   parentage, protection-order, or other proceeding involving the child:
   [________________________________].

5. I have disclosed all known information concerning the child's possible
   membership in, or eligibility for membership in, a federally recognized
   Indian tribe and the ancestry of each biological parent:
   [________________________________].

6. I have not received and have not been promised a fee, compensation, or
   anything else of value as consideration for consenting to or relinquishing
   the child for adoption. Any incidental prenatal, delivery, or postnatal
   expense is disclosed separately to counsel and is not payment
   for this consent.

7. I have reviewed the independent-counsel and language-access selections in
   Section 5 and have completed every applicable certification or affidavit.

8. No person has obtained this consent through fraud, duress, coercion, undue
   influence, intimidation, threat, or physical force.

9. I understand that the court, not this private instrument, decides whether
   the legal requirements for the adoption are satisfied.

7. WITHDRAWAL RIGHT AND ELECTION

Ark. Code Ann. § 9-9-209 provides that a natural person may withdraw consent by
filing an affidavit with the probate division clerk at the address in Section
2 within ten calendar days after the consent is signed or the child is born,
whichever is later. If the final day is a weekend or legal holiday, the
affidavit may be filed on the next working day. No fee is charged for filing
the affidavit. Consent cannot be withdrawn after entry of an adoption decree.

Select exactly one:

• ☐ Ten-day period retained. I do not waive the ten-calendar-day maximum
  withdrawal period.

• ☐ Five-day period elected. I waive the ten-calendar-day period and elect
  to limit the maximum withdrawal period to five calendar days after this
  consent is signed or the child is born, whichever is later.

Date and time consent will be signed: [________________________________]

Later of signing or birth: [________________________________]

Counsel-calculated filing deadline: [________________________________]

The court may excuse the filing period for a biological parent in a stepparent
adoption. Agencies and a minor over twelve whose consent is required are not
governed by the natural-person filing period. Counsel must document any such
route separately rather than changing this parent's election after signing.

8. EXECUTION AND ACKNOWLEDGMENT

8.1 Consenting Parent

I have read this instrument, had the opportunity to ask questions, and sign it
voluntarily.

Parent signature: __________________________________________

Printed name: [________________________________]

Signed on: [__/__/____] at [________] ☐ a.m. ☐ p.m.

Location: [________________________________], Arkansas

8.2 Acknowledgment

State of Arkansas )

County of [________________________________] )

This instrument was acknowledged before me on [__/__/____] by
[CONSENTING PARENT NAME].

Authorized officer signature: ______________________________

Printed name and title: [________________________________]

Commission expiration, if applicable: [________________________________]

Official seal:

9. INDEPENDENT ATTORNEY CERTIFICATION

Complete when the first option in Section 5.1 is selected.

I certify, after the parent's execution of this consent, that I do not
represent any other party in this adoption, I explained to the parent the
effect of consenting to the adoption, and the parent appeared to consent
voluntarily and of the parent's own free will.

Attorney signature: ________________________________________

Printed name: [________________________________]

Arkansas Bar number: [________________________________]

Date and time signed: [________________________________]

10. SWORN WAIVER OF INDEPENDENT COUNSEL

Complete only when the second option in Section 5.1 is selected.

I, [CONSENTING PARENT NAME], state under oath that:

1. I understand that I have been offered limited representation by an attorney
   who does not also represent the petitioner and who would provide independent
   legal advice concerning the effects of consenting to the adoption.

2. I understand that the petitioner is willing to pay for that limited
   representation.

3. After considering my right to an independent attorney, I knowingly and
   voluntarily, without coercion or undue influence from another person, elect
   not to be represented by an attorney for executing this consent and, if I
   elect to withdraw it, for withdrawing the consent.

Parent signature: __________________________________________

Date: [__/__/____]

Subscribed and sworn before me on [__/__/____].

Notary public signature: ___________________________________

Commission expiration: [________________________________]

Official seal:

This affidavit must be filed before the adoption petition is heard.

11. QUALIFIED INTERPRETER CERTIFICATION

Complete when the second option in Section 5.2 is selected.

I certify that, before the parent executed this consent, I accurately
interpreted it into the parent's native language identified above.

Interpreter signature: _____________________________________

Date and time: [________________________________]

12. SWORN WAIVER OF QUALIFIED INTERPRETER

Complete only when the third option in Section 5.2 is selected.

I, [CONSENTING PARENT NAME], state under oath that:

1. My native language is [________________________________].

2. I was offered a qualified interpreter to interpret this consent into my
   native language.

3. I understand that the petitioner is willing to pay for the qualified
   interpreter.

4. I elect not to use a qualified interpreter because:
   - ☐ I am proficient enough in English to understand the legal documents
   without a qualified interpreter; or

• ☐ My attorney can explain the consent and the implications of signing it
  in my native language.

5. I make this election knowingly and voluntarily, without coercion or undue
   influence from another person.

Parent signature: __________________________________________

Date: [__/__/____]

Subscribed and sworn before me on [__/__/____].

Notary public signature: ___________________________________

Commission expiration: [________________________________]

Official seal:

The statute requires this affidavit to be in English, translated into the
parent's native language by a qualified interpreter, and filed before the
adoption petition is heard.

Qualified interpreter who translated the affidavit: [________________]

Translation attached: ☐ Yes

13. FINAL ATTORNEY REVIEW

• ☐ Child was born before execution.
• ☐ Particular proposed adoptive parent or parents are identified.

• ☐ Required-consent analysis is complete for every parent, custodian, agency,
  court, spouse, and child whose role may be relevant.

• ☐ Correct court, county, clerk address, and case information are inserted.

• ☐ Independent counsel, statutory exception, or sworn waiver is complete.
• ☐ Interpreter, statutory exception, or translated sworn waiver is complete.
• ☐ Exactly one withdrawal period was selected and independently calculated.

• ☐ No private-contract default, fee-shifting, indemnity, arbitration, jury
  waiver, assignment, survival, specific-performance, or e-signature clause
  remains.

• ☐ Any expense or reimbursement is separately disclosed and reviewed.

• ☐ Current local filing instructions and required attachments are confirmed.
• ☐ Parent received a complete copy of the signed instrument.

SOURCES AND REFERENCES

• Act 713 of 2025 — current amendments to Ark. Code Ann. §§ 9-9-206 and 9-9-208
• Act 599 of 2021 — independent-counsel and interpreter safeguards
• Act 993 of 2021 — withdrawal of consent