CONSENT TO ADOPTION AND RELINQUISHMENT OF PARENTAL RIGHTS
(Arkansas – Court-Ready Template)
[// GUIDANCE: This template is drafted for use in private or agency adoptions governed by Arkansas law. Customize bracketed items, remove inapplicable provisions, and confirm all statutory references against the latest Arkansas Code before filing.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Revocation, Default & Remedies
- Risk Allocation (Not Applicable)
- Dispute Resolution
- General Provisions
- Execution Block & Notarization
1. DOCUMENT HEADER
1.1 Title.
CONSENT TO ADOPTION AND RELINQUISHMENT OF PARENTAL RIGHTS (the “Consent”).
1.2 Parties.
(a) Birth Parent(s): [FULL LEGAL NAME(S) OF BIRTH PARENT(S)] (“Birth Parent”).
(b) Child: [CHILD’S NAME] (the “Child”), born [DATE OF BIRTH] in [PLACE OF BIRTH].
(c) Prospective Adoptive Parent(s): [NAME(S)] (“Adoptive Parent”).
[// GUIDANCE: List agency, guardian ad litem, or Arkansas Department of Human Services (“DHS”) if applicable.]
1.3 Effective Date & Jurisdiction.
This Consent is executed on [DATE] (the “Effective Date”) and is governed by the Arkansas Revised Uniform Adoption Act, Ark. Code Ann. § 9-9-101 et seq., and any applicable Arkansas Department of Human Services regulations (collectively, the “Arkansas Adoption Law”). Exclusive jurisdiction lies in the [NAME OF COUNTY] Circuit Court, Family Division (the “Family Court”).
1.4 Recitals.
A. Birth Parent is the legal parent of the Child.
B. Adoptive Parent desires to adopt the Child.
C. Birth Parent desires voluntarily to relinquish all parental rights to, and consent to the permanent adoption of, the Child by Adoptive Parent.
D. Arkansas Adoption Law requires written consent executed in accordance with statutory timing, counseling, and revocation provisions.
2. DEFINITIONS
“Act” means the Arkansas Adoption Law.
“Consent” has the meaning assigned in Section 1.1.
“Consent Effective Time” means 12:01 a.m. Central Time on the day following expiration of the Revocation Period.
“Counseling Services” means pre- and post-placement counseling offered by a licensed social worker, counselor, or mental-health professional in accordance with DHS guidelines.
“Family Court” has the meaning assigned in Section 1.3.
“Revocation Period” has the meaning assigned in Section 6.1.
3. OPERATIVE PROVISIONS
3.1 Voluntary Relinquishment.
Birth Parent hereby irrevocably relinquishes, transfers, and surrenders to Adoptive Parent all parental rights, duties, and obligations, including without limitation the rights of custody, control, visitation, decision-making, inheritance, and support, subject only to the Revocation Period set forth in Section 6.1.
3.2 Consent to Adoption.
Birth Parent expressly and unconditionally consents to the adoption of the Child by Adoptive Parent and to entry of a Final Decree of Adoption by the Family Court.
3.3 Timing of Execution.
(a) A Birth Mother may not execute this Consent until at least the moment of the Child’s live birth.
(b) A Birth Father may execute this Consent at any time after conception.
[Ark. Code Ann. § 9-9-206(d) (2023).]
3.4 Consideration.
Birth Parent acknowledges receipt of lawful consideration, if any, as disclosed in the adoption petition and approves any reasonable expenses as permitted under Ark. Code Ann. § 9-9-211.
3.5 Conditions Precedent.
This Consent is conditioned upon:
(a) Completion of any statutorily required counseling (Section 3.6); and
(b) Filing of this Consent with the Family Court in the underlying adoption matter, Cause No. [______].
3.6 Counseling Requirements.
(a) Birth Parent affirms that Counseling Services were explained and offered at no cost.
(b) Birth Parent [HAS RECEIVED / HEREBY WAIVES] Counseling Services.
[// GUIDANCE: Strike inapplicable option. Maintain documentation in agency file.]
4. REPRESENTATIONS & WARRANTIES
Birth Parent represents and warrants, as of the Effective Date:
4.1 Authority & Capacity. Birth Parent is the Child’s legal parent, over eighteen (18) years of age, and legally competent to execute this Consent.
4.2 Voluntariness. Execution is voluntary, without duress, fraud, or undue influence.
4.3 Exclusivity of Rights. No other person or entity holds parental rights to the Child unless expressly disclosed in Schedule A.
4.4 No Pending Litigation. No prior court order limits Birth Parent’s authority to consent, except as set forth in Schedule B (if any).
4.5 Accurate Disclosures. All information provided herein and in any related affidavit is true, complete, and accurate.
4.6 Survival. Representations and warranties survive the Consent Effective Time.
5. COVENANTS & RESTRICTIONS
5.1 Future Cooperation. Birth Parent shall execute any additional instruments reasonably requested to effectuate the adoption.
5.2 Non-Interference. After the Consent Effective Time, Birth Parent shall not challenge, obstruct, or interfere with the adoption.
5.3 Confidentiality. Birth Parent shall maintain the confidentiality of post-placement identifying information unless disclosure is authorized by Arkansas law or court order.
5.4 Updates to Medical History. Birth Parent shall provide any material updates to the Child’s medical or genetic history until entry of the Final Decree of Adoption.
6. REVOCATION, DEFAULT & REMEDIES
6.1 Revocation Period.
In accordance with Ark. Code Ann. § 9-9-209(a) (2023), Birth Parent may rescind this Consent by filing a sworn written revocation with the Clerk of the Family Court within ten (10) calendar days after the later of (i) the Effective Date or (ii) the Child’s date of birth (the “Revocation Period”).
6.2 Effect of Timely Revocation.
Upon timely revocation:
(a) This Consent shall be null and void;
(b) Physical custody of the Child shall revert to Birth Parent or as otherwise ordered by the Family Court; and
(c) All parties shall bear their own costs and fees absent court order.
6.3 Post-Revocation Period Challenge.
After the Revocation Period expires, this Consent is final and may be set aside only upon clear and convincing evidence of fraud or duress, as provided in Ark. Code Ann. § 9-9-209(b).
6.4 Remedies.
The Family Court retains full equitable powers, including issuance of injunctive relief to preserve the Child’s placement and best interests.
7. RISK ALLOCATION (NOT APPLICABLE)
7.1 Indemnification. Not applicable by agreement of the parties and due to the nature of this Consent.
7.2 Limitation of Liability. Not applicable.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Consent and any dispute arising hereunder are governed exclusively by the Arkansas Adoption Law and other applicable Arkansas statutes.
8.2 Forum Selection. Exclusive venue and jurisdiction lie in the [NAME OF COUNTY] Family Court.
8.3 Arbitration. Arbitration is not available for matters governed by the Family Court’s exclusive jurisdiction.
8.4 Jury Trial Waiver. Pursuant to Ark. Code Ann. § 16-64-130 and Family Court practice, the parties waive any right to jury trial; all issues shall be determined by the Family Court judge.
8.5 Injunctive Relief. The Family Court may enter temporary or permanent injunctive orders to ensure the Child’s continuous placement with Adoptive Parent pending final adjudication.
9. GENERAL PROVISIONS
9.1 Entire Agreement. This Consent constitutes the entire agreement and understanding of the parties regarding the subject matter and supersedes all prior oral or written agreements.
9.2 Amendments; Waivers. No amendment or waiver is valid unless in a writing executed with the same formalities as this Consent and approved by the Family Court.
9.3 Assignment. Parental rights are personal in nature and non-assignable by Birth Parent.
9.4 Severability. If any provision is deemed invalid, the remaining provisions remain in full force to the extent consistent with Arkansas public policy and the Child’s best interests.
9.5 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original. Facsimile, PDF, and compliant electronic signatures are binding as originals.
9.6 Headings. Headings are for convenience only and do not affect interpretation.
10. EXECUTION BLOCK & NOTARIZATION
IN WITNESS WHEREOF, the undersigned have executed this Consent as of the Effective Date.
10.1 Birth Parent
[NAME], Birth [Mother/Father]
Date: ____
Address: _____
Phone/Email: _______
[// GUIDANCE: If both parents are executing, duplicate the signature block.]
10.2 Agency / DHS Representative (if applicable)
[NAME & TITLE]
[AGENCY / DHS]
Date: ____
10.3 Acceptance by Prospective Adoptive Parent (Optional)
[NAME], Adoptive Parent
Date: ____
[NAME], Adoptive Parent
Date: ____
10.4 Notary Acknowledgment
State of Arkansas )
County of [__] )
On this _ day of _, 20____, before me, a Notary Public duly commissioned, personally appeared [NAME(S) OF SIGNATORY(IES)], known to me (or satisfactorily proven) to be the person(s) whose name(s) are subscribed to the foregoing instrument, and acknowledged that he/she/they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
My Commission Expires: ___
Seal: ☐
[// GUIDANCE:
1. File original Consent with the Petition for Adoption or as directed by the Family Court.
2. Provide certified copies to all parties.
3. Retain proof of Counseling Services and any revocation tolling events in the adoption file.
4. Verify that all statutory timing requirements are satisfied prior to submission.]