PARENTAL CONSENT TO ADOPTION
Commonwealth of Kentucky
Prepared Pursuant to KRS Chapter 199
CRITICAL NOTICE TO CONSENTING PARENT: By signing this document, you are voluntarily giving up all of your legal rights as a parent to the child named below. This includes the right to custody, visitation, decision-making authority, and inheritance. Under KRS 199.505, you may petition the court to withdraw your consent at any time before the entry of the final decree of adoption, but the court will grant withdrawal only upon a showing that it is in the best interest of the child. After the final decree of adoption is entered pursuant to KRS 199.520, your consent becomes permanently irrevocable except upon proof of fraud or duress. You have the right to consult with an attorney before signing this consent. You are strongly urged to do so.
TABLE OF CONTENTS
- Identification of Parties
- Recitals and Background
- Statutory Requirements and Acknowledgments
- Consent to Adoption
- Relinquishment of Parental Rights
- Representations and Warranties of Consenting Parent
- Counseling Certification
- Revocation Rights Under KRS 199.505
- Rights of Putative Father (If Applicable)
- Post-Adoption Contact Agreement (Optional)
- General Provisions
- Execution and Acknowledgment
- Witness Attestations
- Judicial or Notarial Acknowledgment
- Exhibit List
1. IDENTIFICATION OF PARTIES
A. Consenting Parent
| Field | Information |
|---|---|
| Full Legal Name | [________________________________] |
| Date of Birth | [__/__/____] |
| Social Security Number (last 4) | XXX-XX-[____] |
| Current Address | [________________________________] |
| City, State, ZIP | [________________________________] |
| County of Residence | [________________________________] |
| Telephone | [________________________________] |
| Relationship to Child | ☐ Biological Mother ☐ Biological Father ☐ Legal Guardian ☐ Other: [________________________________] |
B. Child
| Field | Information |
|---|---|
| Full Legal Name | [________________________________] |
| Date of Birth | [__/__/____] |
| Place of Birth (City/County) | [________________________________], Kentucky |
| Sex | ☐ Male ☐ Female |
| Social Security Number (last 4) | XXX-XX-[____] |
| Current Residence | [________________________________] |
C. Prospective Adoptive Parent(s)
| Field | Adoptive Parent 1 | Adoptive Parent 2 (if applicable) |
|---|---|---|
| Full Legal Name | [________________________________] | [________________________________] |
| Date of Birth | [__/__/____] | [__/__/____] |
| Current Address | [________________________________] | [________________________________] |
| County of Residence | [________________________________] | [________________________________] |
| Relationship to Child (if any) | [________________________________] | [________________________________] |
D. Licensed Child-Placing Agency (if applicable)
| Field | Information |
|---|---|
| Agency Name | [________________________________] |
| License Number | [________________________________] |
| Address | [________________________________] |
| Contact Person | [________________________________] |
| Telephone | [________________________________] |
E. Court Information
| Field | Information |
|---|---|
| Court | [________________________________] Family Court / Circuit Court |
| County | [________________________________] County, Kentucky |
| Case Number | [________________________________] |
2. RECITALS AND BACKGROUND
WHEREAS, Consenting Parent is the ☐ biological mother / ☐ biological father / ☐ legal guardian of the Child identified above, and possesses legal authority to consent to adoption under KRS 199.500;
WHEREAS, Consenting Parent desires to voluntarily consent to the adoption of the Child by the Prospective Adoptive Parent(s) identified above;
WHEREAS, KRS 199.500 requires that consent to adoption be given in writing and be executed in accordance with statutory formalities, including execution before a judge of the District Court or Circuit Court of the county in which the consenting party resides, or before a notary public;
WHEREAS, KRS 199.502 requires that the consent be voluntary and informed, and that the consenting parent be advised of legal rights and consequences;
WHEREAS, all statutory prerequisites for adoption under KRS Chapter 199 have been or will be satisfied;
NOW, THEREFORE, for good and valuable consideration, including the welfare and best interests of the Child, the Consenting Parent states and agrees as follows:
3. STATUTORY REQUIREMENTS AND ACKNOWLEDGMENTS
A. Timing of Consent (KRS 199.500(5) and (7))
3.1. ☐ Birth Mother Consent: Consenting Parent affirms that this consent is executed no earlier than seventy-two (72) hours after the birth of the Child, as required by KRS 199.500(7) for birth mothers. The Child was born on [__/__/____] at [____] ☐ a.m. / ☐ p.m. This consent is executed on [__/__/____] at [____] ☐ a.m. / ☐ p.m., which is more than seventy-two (72) hours after birth.
3.2. ☐ Birth Father / Other Consent: Consenting Parent is a birth father, legal guardian, or other person whose consent is required. This consent may be executed at any time after the Child's birth but before entry of the final decree of adoption.
B. Manner of Execution (KRS 199.500(1))
3.3. This consent is executed:
☐ Before a judge of the ☐ District Court / ☐ Circuit Court / ☐ Family Court of [________________________________] County, Kentucky
☐ Before a notary public, as permitted by KRS 199.500(1)
C. Persons Whose Consent Is Required (KRS 199.500(1))
3.4. Under KRS 199.500(1), the following persons must consent to the adoption (check all that apply):
☐ The living biological mother of the Child
☐ The living biological father of the Child (if paternity has been established)
☐ Any legal guardian of the Child
☐ The Cabinet for Health and Family Services (if the Child is committed to the Cabinet)
☐ The child-placing agency (if the Child is committed to an agency)
☐ The Child, if fourteen (14) years of age or older (KRS 199.500(2))
3.5. The following persons' consent ☐ has been obtained / ☐ is not required because: [________________________________]
D. Consent Not Required (KRS 199.480)
3.6. Consent of the following person(s) is not required because (check if applicable):
☐ The parent has been adjudged mentally disabled per KRS 199.480(1)
☐ Parental rights have been terminated per KRS 625.040 et seq.
☐ The parent has abandoned the Child per KRS 199.480(2)
☐ The putative father has failed to register with the Kentucky Putative Father Registry per KRS 199.585
☐ Other statutory basis: [________________________________]
4. CONSENT TO ADOPTION
4.1. Grant of Consent. Consenting Parent hereby voluntarily, knowingly, and freely consents to the adoption of the Child by the Prospective Adoptive Parent(s), in accordance with KRS 199.500 and all other applicable provisions of Kentucky law.
4.2. Specific or General Consent. This consent is:
☐ Specific Consent: Consenting Parent consents to adoption by the specific Prospective Adoptive Parent(s) named in Section 1(C) above. If the named Prospective Adoptive Parent(s) do not complete the adoption, this consent shall be void.
☐ General Consent: Consenting Parent consents to adoption by any suitable person(s) approved by the Court and/or the Cabinet for Health and Family Services or licensed child-placing agency.
4.3. Waiver of Notice. Consenting Parent waives any requirement of personal notice of future adoption proceedings, except as required by the Court or by Kentucky law.
5. RELINQUISHMENT OF PARENTAL RIGHTS
5.1. Upon execution of this consent and the entry of the final decree of adoption, Consenting Parent voluntarily, knowingly, and permanently relinquishes all parental rights, privileges, duties, and obligations with respect to the Child, including but not limited to:
☐ Physical custody and legal custody
☐ Visitation and parenting time
☐ Decision-making authority regarding education, healthcare, and religion
☐ The right to consent or withhold consent to marriage, enlistment, or major medical treatment
☐ The right to inheritance from the Child
☐ The Child's right to inheritance from Consenting Parent
☐ All other rights and obligations arising from the parent-child relationship
5.2. Consenting Parent understands that upon entry of the final decree of adoption under KRS 199.520, the Prospective Adoptive Parent(s) will assume all rights and responsibilities of parenthood, and the Child will become the legal child of the Adoptive Parent(s) for all purposes under Kentucky law.
6. REPRESENTATIONS AND WARRANTIES OF CONSENTING PARENT
Consenting Parent represents, warrants, and affirms that:
6.1. Age and Competence. Consenting Parent is at least eighteen (18) years of age and is legally competent to execute this consent. ☐ If Consenting Parent is under eighteen (18), a guardian ad litem has been appointed by the Court to protect Consenting Parent's interests.
6.2. Voluntariness. Consenting Parent is acting voluntarily, without duress, coercion, fraud, or undue influence from any person, including the Prospective Adoptive Parent(s), any agency, or any attorney.
6.3. Sobriety. Consenting Parent is not under the influence of alcohol, narcotics, sedatives, or any substance that would impair judgment or the ability to understand the nature and consequences of this consent.
6.4. Understanding of Consequences. Consenting Parent has been fully informed of and understands:
- The legal consequences of signing this consent
- The right to revoke consent before the final decree under KRS 199.505
- The permanent and irrevocable nature of adoption after entry of the final decree
- The termination of all parental rights, duties, and obligations
- Available alternatives to adoption, including parenting, temporary foster care, and kinship care
- Available counseling and support services
6.5. No Prohibited Compensation. No money, property, or other thing of value has been offered, given, or received in exchange for this consent, except for reasonable and customary pregnancy-related and adoption-related expenses as permitted by KRS 199.590(1). Such permitted expenses include:
☐ Medical expenses: $[________________________________]
☐ Hospital expenses: $[________________________________]
☐ Legal fees: $[________________________________]
☐ Counseling fees: $[________________________________]
☐ Living expenses during pregnancy: $[________________________________]
☐ Other permitted expenses: $[________________________________]
6.6. Accuracy of Information. All information provided in this consent and related documents is true, correct, and complete to the best of Consenting Parent's knowledge.
6.7. No Pending Litigation. There is no pending litigation, court order, or other legal proceeding that would prohibit or restrict this adoption, except as disclosed to the Court.
7. COUNSELING CERTIFICATION
7.1. Consenting Parent certifies that (check one):
☐ Counseling Received. Consenting Parent has received pre-adoption counseling from [________________________________], a licensed counselor/social worker (License No. [________________________________]), on [__/__/____]. The counseling addressed:
- The legal consequences of consent to adoption
- The revocation rights under KRS 199.505
- Alternative parenting options and support services
- Emotional and psychological aspects of the adoption decision
- Post-adoption resources and support
- A Counseling Certificate is attached as Exhibit A
☐ Counseling Offered but Declined. Consenting Parent was offered counseling but has voluntarily declined. Consenting Parent understands the right to counseling and makes an informed choice to proceed without it. Written waiver is attached as Exhibit A.
☐ Counseling Provided by Agency. The licensed child-placing agency, [________________________________], provided counseling as part of its adoption services. Documentation is attached as Exhibit A.
8. REVOCATION RIGHTS UNDER KRS 199.505
8.1. Right to Revoke Before Final Decree. Consenting Parent is advised and acknowledges that under KRS 199.505, this consent may be revoked at any time before the entry of the final decree of adoption by filing a written petition with the Court.
8.2. Court Discretion. If a petition to revoke consent is filed, the Court will conduct a hearing and may permit revocation only upon a finding that revocation is in the best interest of the Child. The burden of proof is on the person seeking revocation.
8.3. Irrevocability After Final Decree. Upon entry of the final decree of adoption under KRS 199.520, this consent becomes permanently irrevocable, and the adoption may be challenged only upon proof of fraud, duress, or lack of capacity, as provided by Kentucky law.
8.4. Written Acknowledgment. By initialing below, Consenting Parent acknowledges understanding of the revocation provisions:
Initials: [____] I understand my right to petition for revocation before the final decree.
Initials: [____] I understand that after the final decree, my consent is irrevocable.
Initials: [____] I understand that revocation is not automatic and is subject to the Court's determination of the Child's best interest.
9. RIGHTS OF PUTATIVE FATHER (IF APPLICABLE)
9.1. ☐ Not Applicable. The biological father's paternity has been established and he is a party to this consent or a separate consent has been or will be obtained.
9.2. ☐ Putative Father Registry Search. A search of the Kentucky Putative Father Registry (KRS 199.585) has been conducted by the Cabinet for Health and Family Services. The search results indicate:
☐ No registration was found. Putative father's consent is not required.
☐ A registration was found for [________________________________]. Appropriate notice has been provided.
9.3. ☐ Unknown Father. The identity of the biological father is unknown. A diligent search has been conducted and notice by publication has been ☐ ordered / ☐ is being sought pursuant to KRS 199.500 and CR 4.06.
10. POST-ADOPTION CONTACT AGREEMENT (OPTIONAL)
10.1. ☐ No Post-Adoption Contact. Consenting Parent does not request any post-adoption contact with the Child.
10.2. ☐ Post-Adoption Contact Requested. Consenting Parent and Prospective Adoptive Parent(s) have voluntarily agreed to the following post-adoption contact arrangement. This agreement:
- Is not a condition of consent to adoption
- Is not enforceable as a matter of right under Kentucky law
- Does not affect the validity of the consent or the adoption
- May be modified by the Adoptive Parent(s) at any time in the best interest of the Child
Contact arrangement: [________________________________]
Frequency: [________________________________]
Method: ☐ Letters ☐ Photographs ☐ Email ☐ In-person visits ☐ Other: [________________________________]
11. GENERAL PROVISIONS
11.1. Governing Law. This consent is governed by and construed in accordance with the laws of the Commonwealth of Kentucky, including KRS Chapter 199 and all related statutes and regulations.
11.2. Exclusive Jurisdiction. Exclusive jurisdiction and venue for all matters relating to this consent and the adoption reside in the [________________________________] County Family Court (or Circuit Court), Commonwealth of Kentucky.
11.3. Severability. If any provision of this consent is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.
11.4. Entire Agreement. This consent, together with any exhibits, constitutes the entire agreement of Consenting Parent regarding the adoption of the Child.
11.5. Amendment. This consent may be amended only by written instrument executed with the same formalities as this consent and approved by the Court.
11.6. Binding Effect. This consent is binding upon Consenting Parent and Consenting Parent's heirs, executors, administrators, and legal representatives.
11.7. Confidentiality. Pursuant to KRS 199.570, adoption records are confidential. Consenting Parent agrees to maintain the confidentiality of all identifying information concerning the Prospective Adoptive Parent(s) unless disclosure is required by law or ordered by the Court.
11.8. Counterparts and Electronic Signatures. This consent may be executed in counterparts. However, the original signed consent bearing the notarial or judicial acknowledgment must be filed with the Court.
12. EXECUTION AND ACKNOWLEDGMENT
IN WITNESS WHEREOF, Consenting Parent has executed this Consent to Adoption on the date set forth below.
CONSENTING PARENT
I, [________________________________], have read this entire Consent to Adoption, understand its contents and legal consequences, and execute it voluntarily and of my own free will.
Signature: _____________________________________________
Printed Name: [________________________________]
Date: [__/__/____]
Time: [____] ☐ a.m. / ☐ p.m.
13. WITNESS ATTESTATIONS
Each witness declares that: (i) the Consenting Parent appeared to execute this consent voluntarily and with full understanding of its consequences; (ii) the Consenting Parent did not appear to be under duress, coercion, or the influence of any impairing substance; and (iii) the witness is at least eighteen (18) years of age.
Witness 1
Signature: _____________________________________________
Printed Name: [________________________________]
Address: [________________________________]
Date: [__/__/____]
Witness 2
Signature: _____________________________________________
Printed Name: [________________________________]
Address: [________________________________]
Date: [__/__/____]
14. JUDICIAL OR NOTARIAL ACKNOWLEDGMENT
Option A: Acknowledgment Before a Judge (Preferred under KRS 199.500)
I, [________________________________], Judge of the ☐ District Court / ☐ Circuit Court / ☐ Family Court of [________________________________] County, Kentucky, certify that:
- The Consenting Parent appeared before me on [__/__/____];
- I have determined that the Consenting Parent is acting voluntarily and with full understanding of the legal consequences of this consent;
- The Consenting Parent was advised of the right to revoke consent under KRS 199.505;
- This consent was executed in compliance with KRS 199.500.
Judge's Signature: _____________________________________________
Printed Name: [________________________________]
Date: [__/__/____]
Option B: Notarial Acknowledgment
Commonwealth of Kentucky )
) SS:
County of [________________________________] )
On this [____] day of [________________________________], 20[____], before me, a Notary Public in and for the Commonwealth of Kentucky, personally appeared [________________________________], known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing Consent to Adoption, and acknowledged that ☐ he / ☐ she executed the same as ☐ his / ☐ her free and voluntary act for the purposes therein contained.
Notary Public Signature: _____________________________________________
Printed Name: [________________________________]
My Commission Expires: [__/__/____]
Notary ID Number: [________________________________]
[NOTARIAL SEAL]
15. EXHIBIT LIST
| Exhibit | Description |
|---|---|
| A | Counseling Certificate or Waiver of Counseling |
| B | Child's Birth Certificate |
| C | Putative Father Registry Search Results (if applicable) |
| D | Accounting of Permitted Expenses Paid (KRS 199.590) |
| E | Post-Adoption Contact Agreement (if applicable) |
| F | Guardian ad Litem Appointment (if Consenting Parent is a minor) |
| G | Other: [________________________________] |
PRACTICE NOTES FOR KENTUCKY PRACTITIONERS
Who Must Consent (KRS 199.500(1))
- The living biological mother
- The living biological father whose paternity has been judicially established or acknowledged
- Any person or agency with legal custody or guardianship
- The Cabinet for Health and Family Services (if child is committed)
- The child, if age 14 or older
72-Hour Waiting Period
KRS 199.500(7) requires that a birth mother's consent not be executed earlier than 72 hours after the birth of the child. There is no statutory waiting period for birth fathers or other consenting parties.
Revocation Under KRS 199.505
- Consent may be revoked by petition to the court any time before the final decree
- Court must find revocation is in child's best interest
- After the final decree, consent is irrevocable except for fraud, duress, or incapacity
- No automatic revocation period exists in Kentucky
Prohibited Payments (KRS 199.590)
- It is a felony to sell or purchase a child
- Only reasonable pregnancy-related and adoption-related expenses may be paid
- All payments must be disclosed to the Court
- The Court must approve the reasonableness of expenses
Putative Father Registry (KRS 199.585)
- Kentucky maintains a Putative Father Registry through the Cabinet
- A putative father must register to receive notice of adoption proceedings
- Failure to register may waive the right to consent
- Search of the registry should be documented
Interlocutory and Final Decree Timeline
- KRS 199.510: Interlocutory decree may be entered after investigation
- KRS 199.520: Final decree entered after interlocutory period (typically 90 days to 1 year)
- Consent becomes irrevocable upon entry of the final decree
SOURCES AND REFERENCES
- KRS 199.500 - Consent to adoption; requirements, timing, and execution
- KRS 199.502 - Voluntary and informed consent requirements
- KRS 199.505 - Withdrawal or revocation of consent
- KRS 199.470 - Petition for adoption; required contents
- KRS 199.473 - Who may be adopted; who may adopt
- KRS 199.480 - When consent is not required
- KRS 199.490 - Filing of petition; investigation by Cabinet
- KRS 199.510 - Hearing and interlocutory decree of adoption
- KRS 199.520 - Final decree of adoption
- KRS 199.570 - Confidentiality of adoption records
- KRS 199.585 - Putative Father Registry
- KRS 199.590 - Prohibited payments; permissible expenses
- KRS 625.040 et seq. - Involuntary termination of parental rights
- CR 4.06 - Service by warning order (publication)
- Cabinet for Health & Family Services v. K.H., 423 S.W.3d 204 (Ky. 2014) - Best interest standard in adoption
- S.B.L. v. E.L.G., 404 S.W.3d 863 (Ky. App. 2013) - Voluntary consent analysis
This template is provided for informational and educational purposes only. It does not constitute legal advice. Adoption is a permanent legal action with profound consequences. Kentucky adoption law is subject to legislative amendment and judicial interpretation. Always verify current statutory text and consult with a qualified Kentucky-licensed attorney before execution. Use of this template does not create an attorney-client relationship.
About This Template
Jurisdiction-Specific
This template is drafted specifically for Kentucky, incorporating applicable state statutes, local court rules, and jurisdiction-specific compliance requirements.
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Drafted using current statutory databases and legal standards for family law. Each template includes proper legal citations, defined terms, and standard protective clauses.
Important Notice
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Last updated: April 2026