Adoption Consent Form - Illinois

FINAL AND IRREVOCABLE CONSENT TO ADOPTION

Before use: This is the general consent for a child already born under 750 ILCS 50/10(A). A consent for adoption by specified people uses the different form in § 10(A-1). Do not sign this born-child consent within 72 hours after birth. Give the signing parent the Birth Parent Rights and Responsibilities-Private Form in § 10(A-2) to read, or read it to the parent, before signing. Section 11(a) governs challenges based on fraud or duress.

In the Circuit Court of [COUNTY] County, Illinois

Case No.: [________________]

I, [PARENT OR OTHER CONSENTING PERSON'S FULL NAME], the [RELATIONSHIP TO CHILD] of [CHILD'S FULL NAME], a ☐ male ☐ female child, state:

1. The child was born on [__/__/____] at [PLACE OF BIRTH].
2. I reside at [STREET ADDRESS], County of [COUNTY], State of [STATE].
3. I am [____] years old.
4. I enter my appearance in this adoption proceeding and waive service of summons on me.
5. I acknowledge that I was provided a copy of the Birth Parent Rights and Responsibilities-Private Form before signing this Consent and had time to read it, or to have it read to me. I understand that failure to receive a right described in that Form does not itself provide a basis to revoke this Consent.
6. I consent and agree to the adoption of the child.
7. I understand that by signing this Consent I irrevocably and permanently give up all custody and other parental rights I have to the child.
8. I understand that the child will be placed for adoption and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this Consent or obtain or recover custody or any other rights over the child.
9. I have read and understand these statements and sign this Consent as my free and voluntary act.

Dated: [__/__/____]

Signature of consenting person: [________________________________]

Printed name: [________________________________]

Certificate of acknowledgment — 750 ILCS 50/10(H), (J)

State of [STATE]

County of [COUNTY]

I, [NAME OF JUDGE OR OTHER AUTHORIZED PERSON], [OFFICIAL TITLE; COURT AND LOCATION, AGENCY, OR COURT DESIGNATION], certify that [CONSENTING PERSON], personally known to me to be the person whose name is subscribed to this Consent, appeared before me in person on [__/__/____] and acknowledged signing and delivering it as a free and voluntary act for its stated purpose.

I fully explained that by signing this Consent the person irrevocably relinquishes parental rights to the child, and the person stated that this is the intended result. I am satisfied that, before signing, the person read or had read to them the Birth Parent Rights and Responsibilities-Private Form.

A court-designated person who takes this acknowledgment cannot be the attorney for the prospective adoptive parents.

Signature of judge or authorized person: [________________________________]

Title and authority: [________________________________]

Date: [__/__/____]

Notary acknowledgment of nonjudge's certificate — 750 ILCS 50/10(K)

Complete this block only when a person other than a judge took the parent's acknowledgment above. The notary acknowledges that person's signature on the certificate; the notary does not take the parent's consent directly.

State of [STATE]

County of [COUNTY]

I, a notary public for [COUNTY, STATE], certify that [AUTHORIZED PERSON'S NAME], personally known to me to be the person whose name is subscribed to the certificate of acknowledgment above, appeared before me on [__/__/____] and acknowledged signing that certificate as a free and voluntary act and that its statements are true.

Notary signature: [________________________________]

Commission expires: [__/__/____]

Notarial seal: [SEAL]

Sources and references

• 750 ILCS 50/9 — signing time
• 750 ILCS 50/10 — statutory consent and acknowledgment forms
• 750 ILCS 50/11 — irrevocability