Adoption Consent Form - Louisiana

ADOPTION CONSENT FORM

Louisiana Act-of-Surrender Preparation Checklist

Do not sign this checklist as an adoption consent. Louisiana Children's Code article 1122 supplies detailed statutory forms and required attachments. A homemade abbreviated consent can omit route-specific declarations, counsel, counseling, capacity, filiation, timing, filing, or authentic-act requirements.

1. Route Selection

Louisiana uses different surrender rules for private and agency adoptions. Intrafamily adoption and any proceeding in which consent may be unnecessary require a separate statutory analysis and are outside this checklist.

Route selected by Louisiana adoption counsel:

• ☐ Private adoption
• ☐ Agency adoption
• ☐ Department of Children and Family Services placement
• ☐ Intrafamily or other route — stop and use the route-specific procedure
• ☐ Route remains disputed or uncertain — stop before preparing an act

Counsel responsible for route analysis: [________________________________]

2. People and Child Information

Surrendering Parent

Full legal name: [________________________________]

Parish of domicile: [________________________________]

Age: [________________________________]

Marital status: [________________________________]

Role: ☐ Mother ☐ Father ☐ Alleged father ☐ Adjudicated father ☐ Other: [____________]

Other Parent

Name: [________________________________]

Last known address: [________________________________]

If unknown, facts supporting that statement: [________________________________]

Child

Birth name or expected name: [________________________________]

Date of birth or expected birth: [__/__/____]

Place of birth: [________________________________]

Indian-child inquiry completed: ☐ Yes ☐ No

Counsel's route-specific finding: [________________________________]

Recipient of Surrender

Person, agency, or representative: [________________________________]

Address: [________________________________]

Capacity: [________________________________]

Filing Court

Court selected under the venue rules incorporated by article 1131: [________________________________]

City and parish: [________________________________]

3. Timing Gate — Article 1130

Do not use one generic waiting or revocation period.

Private Adoption

• A mother's private-adoption Act of Surrender may not be executed earlier than five days following the child's birth.
• A father may execute before birth or after birth, but article 1130 contains different irrevocability rules for an early private surrender.
• An alleged or adjudicated father may execute before or after birth; article 1130(D) states that his surrender is irrevocable upon execution.
• The birth date is excluded from the calculation, and consecutive calendar days include weekends and holidays.

Agency Adoption

Article 1130(E) provides that an Act of Surrender by a birth mother or father as defined in article 1193 for agency adoption may not be executed earlier than three days following birth.

Counsel's calculation:

Route: [________________________________]

Birth date: [__/__/____]

Earliest permitted execution date: [__/__/____]

Date surrender becomes irrevocable: [__/__/____]

Reason and article 1130 paragraph: [________________________________]

The five-day language is not a general five-day right to revoke after signing. Article 1123 makes an Act of Surrender irrevocable upon execution except as article 1130 provides. Fraud, duress, and court dissolution when an adoption cannot be accomplished are separate issues that require counsel.

4. Minor-Parent Gate — Article 1113

If the surrendering parent is a minor, counsel must select the correct article 1113 route.

• ☐ Parent is not a minor.
• ☐ Private adoption: required parent(s) or tutor will join.
• ☐ Private adoption: judicial emancipation or emancipation by marriage applies.
• ☐ Private adoption: court authorization is sought because required persons refuse or cannot be located.
• ☐ Agency surrender: counsel confirmed article 1113(E)'s rule.
• ☐ Intrafamily adoption: separate article 1113(D) analysis completed.

Supporting documents: [________________________________]

5. Pre-Surrender Counseling — Article 1120

Before execution, a surrendering parent must participate in at least two surrender-related counseling sessions with a professional authorized by article 1120. The counselor must execute an affidavit addressing attendance and apparent understanding; any capacity concern and recommended evaluation must be stated.

A major surrendering father may waive the counseling under article 1120(D), but the required attorney-or-counselor affidavit must document the waiver and apparent understanding.

Capacity concern identified: ☐ No ☐ Yes

If yes, court/evaluation route selected: [________________________________]

6. Independent Legal Counsel — Article 1121

For every private-adoption surrender, the surrendering parent and any applicable representative or tutor must be represented at execution by a Louisiana-licensed attorney who is independent of the prospective adoptive parent's attorney and the prohibited affiliated attorneys, firms, and corporations listed in article 1121.

Surrendering parent's attorney: [________________________________]

Louisiana bar number: [________________________________]

Independence confirmed: ☐ Yes

Attorney affidavit prepared and attached: ☐ Yes

Executed copy will be provided to surrendering parent: ☐ Yes

7. Statutory Act Package — Articles 1122 and 1124

Louisiana counsel—not the parties using this checklist—must prepare the current statutory act.

Article 1122 Contents and Form

• ☐ Parent identity, domicile, age, and marital status
• ☐ Other legal or natural parent information
• ☐ Child identity, birth details, and Indian-child statement
• ☐ Recipient identity and address
• ☐ Filing court
• ☐ Correct route-specific timing declaration
• ☐ Capacity and interdiction declaration
• ☐ Minor-parent declaration or attachment, if applicable
• ☐ Irrevocability, parental-rights, fraud, duress, and dissolution declarations
• ☐ Voluntary surrender and final-consent declarations
• ☐ Waiver of notice and service in later adoption proceedings
• ☐ Voluntary-registration information
• ☐ Louisiana domicile or DCFS-custody basis
• ☐ R.S. 14:125.2 advice by independent counsel
• ☐ Route-specific DCFS, opposition-notice, medical-information, and family-history declarations
• ☐ Counseling or permitted waiver declaration
• ☐ Private-adoption independent-counsel declaration
• ☐ Authentic-act form and every required signature
• ☐ Notary and two competent adult witnesses used in the statutory form
• ☐ Copy made available to the surrendering parent

Article 1124 Attachments

• ☐ Completed Statement of Family History
• ☐ Parent's separate affidavit concerning the Statement of Family History
• ☐ Counselor affidavit or permitted waiver affidavit
• ☐ Private-adoption counsel affidavit
• ☐ Minor-parent joinder or court consent, if required
• ☐ Other route-specific attachment: [________________________________]

8. Effect — Article 1123

Counsel has explained that a compliant authentic Act of Surrender:

• grants legal custody of the identified child to the agency or person named or represented in the act;
• grants the surrendering parent's irrevocable consent to the later adoption, subject to article 1130's timing rules; and
• may be dissolved by a court of competent jurisdiction if the adoption cannot be accomplished.

Requested notarized statement after final judgment, if applicable: ☐ Yes ☐ No

9. Filing — Article 1131

Within three days after the surrender becomes irrevocable, exclusive of legal holidays, the responsible agency or prospective-adoptive-parent attorney files the authentic act and the documents specified in article 1131 in a court of proper venue. A later filing requires leave of court for good cause. The court reviews the surrender and accompanying documents for statutory sufficiency.

Responsible filer: [________________________________]

Irrevocability date: [__/__/____]

Legal holidays excluded: [________________________________]

Target filing date: [__/__/____]

Actual filing date: [__/__/____]

Court approval or deficiency notice: [________________________________]

10. Removed Contract Terms

The statutory surrender is not a private settlement agreement. Do not add:

• a generic five-day revocation right;
• post-placement counseling in place of article 1120's pre-surrender sessions;
• default and cure periods;
• prevailing-party attorney fees;
• specific-performance promises;
• assignment, successors, integration, or severability boilerplate;
• counterpart or electronic-signature clauses;
• a private forum-selection clause; or
• a signature block that turns this checklist into an apparent consent.

Sources and References

• La. Ch.C. art. 1113 — minor parents
• La. Ch.C. art. 1120 — pre-surrender counseling
• La. Ch.C. art. 1121 — legal counseling
• La. Ch.C. art. 1122 — contents and statutory forms
• La. Ch.C. art. 1123 — effect of surrender
• La. Ch.C. art. 1124 — family-history package
• La. Ch.C. art. 1130 — time limitations
• La. Ch.C. art. 1131 — filing and court review