PARENTAL CONSENT TO ADOPTION

(Commonwealth of Kentucky – KRS Chapter 199 Compliant)

[// GUIDANCE: This template is intentionally broad so it may be used for a birth mother, birth father, legal guardian, or other person whose consent is required under KRS 199.500. Delete or modify bracketed options to suit the particular party.]

I. DOCUMENT HEADER

A. Title & Parties
1. “Consenting Parent”: [PARENT FULL LEGAL NAME] (“Parent”)
2. “Child”: [CHILD FULL LEGAL NAME], born [DOB] in [CITY/COUNTY, KY] (“Child”)
3. “Prospective Adoptive Parent(s)”: [ADOPTIVE PARENT 1 NAME] and [ADOPTIVE PARENT 2 NAME] (collectively, “Prospective Parent(s)”)
4. “Cabinet” means the Kentucky Cabinet for Health and Family Services, Department for Community Based Services, Division of Protection and Permanency.

B. Effective Date & Jurisdiction
Executed on [DATE] (the “Effective Date”) pursuant to the laws of the Commonwealth of Kentucky, including KRS 199.500–199.590 (“Kentucky Adoption Law”). Venue for all proceedings shall lie exclusively in the [NAME OF COUNTY] Family Court.

C. Recitals
WHEREAS, Parent is the legal [mother/father/guardian] of Child and possesses the authority to consent to adoption;
WHEREAS, Parent desires to voluntarily and irrevocably* consent to the adoption of Child by Prospective Parent(s); and
WHEREAS, Kentucky Adoption Law requires written, informed consent executed in accordance with statutory formalities;

NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Parent states as follows:

II. DEFINITIONS

The following capitalized terms shall have the meanings set forth below. Terms defined herein shall apply equally to singular and plural forms.

1. “Consent” means this written instrument evidencing Parent’s voluntary relinquishment of parental rights to facilitate the adoption of Child.
2. “Court” means the Family Court or Circuit Court of competent jurisdiction in [COUNTY], Kentucky.
3. “Counseling” means the pre-execution counseling required by KRS 199.500 et seq. and associated regulations.
4. “Revocation Period” means the limited period during which this Consent may be withdrawn as detailed in Section VI.
5. “Final Decree” means the judgment of adoption entered by the Court pursuant to Kentucky Adoption Law.

III. OPERATIVE PROVISIONS

3.01 Consent Timing

a. Parent affirms that this Consent is executed no earlier than seventy-two (72) hours after the birth of Child, as required for a birth mother under KRS 199.500(7).
b. If Parent is a birth father or other legal guardian, Parent acknowledges that Consent may be executed at any time after Child’s birth but before entry of the Final Decree.

3.02 Grant of Consent and Relinquishment of Rights

Parent hereby:
1. Consents to the adoption of Child by Prospective Parent(s);
2. Voluntarily, knowingly, and permanently relinquishes all parental rights, duties, and obligations with respect to Child, including but not limited to custody, control, visitation, inheritance, and decision-making authority;
3. Waives any requirement of personal notice of future adoption proceedings, except as required by the Court.

3.03 Conditions Precedent

This Consent shall become effective upon:
a. Proper execution before a judge of the District or Family Court, or before a duly authorized notary public, as permitted by KRS 199.500; and
b. Filing with the Court concurrently with or prior to the filing of the Petition for Adoption.

3.04 Counseling Certification

Parent certifies that:
a. Parent has received Counseling by [NAME AND CREDENTIALS OF COUNSELOR/AGENCY] on [DATE];
b. The Counseling addressed (i) the legal consequences of adoption, (ii) the Revocation Period, (iii) alternative parenting options, and (iv) available support services; and
c. A Counseling certificate is attached hereto as Exhibit A.

IV. REPRESENTATIONS & WARRANTIES

Parent represents, warrants, and covenants that:
1. Parent is at least eighteen (18) years of age and legally competent.
2. Parent is the [biological/legal] parent or guardian of Child and no other person’s consent is required of Parent’s rights in Child except as disclosed to the Court.
3. Parent is acting voluntarily, without duress, coercion, or undue influence, and fully understands the finality of this Consent.
4. No compensation or thing of value, other than those permitted by Kentucky law (e.g., pregnancy-related expenses), has been offered or received in exchange for this Consent.
5. Parent is not under the influence of alcohol, narcotics, or any substance that would impair judgment.
6. The information provided herein is true, correct, and complete to the best of Parent’s knowledge.

V. COVENANTS & RESTRICTIONS

1. Further Assurances. Parent shall execute and deliver such additional documents and take such further actions as the Court may reasonably require to effectuate the adoption.
2. Confidentiality. Parent shall maintain the confidentiality of all identifying information concerning Prospective Parent(s) unless disclosure is required by law or permitted by written agreement of the parties and approval of the Court.
3. Cooperation. Parent will cooperate with the Cabinet, the Court, and Prospective Parent(s) in all proceedings necessary to obtain the Final Decree.

VI. REVOCATION, DEFAULT & REMEDIES

6.01 Revocation Rights

a. Parent may file a written notice of revocation with the Court any time before entry of the Final Decree.
b. The Court may, in its discretion and upon a finding of good cause and that revocation is in Child’s best interest, permit withdrawal of this Consent.
c. Upon entry of the Final Decree, this Consent becomes irrevocable, except upon a showing of fraud, duress, or lack of capacity as provided by Kentucky law.

6.02 Default; Attorney Fees

Should Parent breach any covenant herein and the Court determines such breach causes delay or prejudice, the Court may award reasonable attorney fees and costs incurred by Prospective Parent(s) or the Cabinet in responding to the breach.

VII. RISK ALLOCATION

Indemnification and limitation of liability are not applicable to this family-law instrument. The parties’ rights are governed exclusively by Kentucky Adoption Law and the equitable powers of the Court.

VIII. DISPUTE RESOLUTION

1. Governing Law. This Consent shall be construed and enforced in accordance with the laws of the Commonwealth of Kentucky.
2. Forum Selection. Exclusive jurisdiction and venue shall reside in the [COUNTY] Family Court.
3. Arbitration. Arbitration is not available for matters relating to adoption under Kentucky law.
4. Jury Waiver. Pursuant to KY Family Court procedures, adoption proceedings are heard without a jury.
5. Injunctive Relief. The Court retains authority to enter orders for the permanent placement and protection of Child.

IX. GENERAL PROVISIONS

1. Entire Agreement. This Consent, together with any exhibits, constitutes the entire agreement of Parent regarding the adoption of Child.
2. Amendment & Waiver. No amendment or waiver shall be effective unless made in writing and approved by the Court.
3. Severability. If any provision of this Consent is held unenforceable, the remaining provisions shall remain in full force to the extent permitted by law.
4. Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original. Facsimile, scanned, or verified electronic signatures shall be deemed originals for all purposes.
5. Successors & Assigns. This Consent is binding upon Parent and Parent’s heirs, legal representatives, and assigns.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, Parent has executed this Consent on the Effective Date set forth above.

PARENT (Consenting Party)

Signature: _________
Name: [PARENT FULL LEGAL NAME]
Address: [ADDRESS]
Phone: [PHONE]
Date: [DATE]

[// GUIDANCE: If both birth parents are consenting on the same form, duplicate this block for the second parent.]

ACKNOWLEDGMENT

Commonwealth of Kentucky )
County of [COUNTY] ) SS:

Subscribed, sworn to, and acknowledged before me by [PARENT FULL LEGAL NAME] this ___ day of __, 20.

Notary Public / Judge, Kentucky Court
My Commission Expires: ___

EXHIBIT A – COUNSELING CERTIFICATE

[Attach written certification signed by the licensed counselor or authorized agency representative verifying compliance with Kentucky Adoption Law counseling requirements.]

[// GUIDANCE: File the executed Consent with the Petition for Adoption as required by KRS 199.470 and 199.500. Verify that all statutory notices (e.g., putative father registry search) have been completed prior to finalization.]

© [YEAR] Drafted by [LAW FIRM NAME / ATTORNEY NAME], Kentucky Bar # [BAR NO.].
This template is provided as a sample only and must be tailored to the specific facts and current law before use.