Adoption Consent Form - Minnesota

PARENTAL CONSENT TO ADOPTION — MINNESOTA

Use and review. This is a preparation form for a parent consenting under Minn. Stat. § 259.24 in an agency or stepparent adoption. If a direct placement uses the judicial-consent procedure in § 259.47, subd. 7, use the commissioner-prepared form required by that subdivision. This preparation form is not for that procedure. Have the agency or an adoption attorney confirm that § 259.24, subd. 6a withdrawal applies and check every required consent, notice, and filing step before execution. A signed consent alone does not terminate parental rights.

1. CHILD AND PROPOSED ADOPTION

Child's full legal name: [CHILD NAME]
Date and place of birth: [DATE AND PLACE]
Consenting parent's full legal name: [PARENT NAME]
Parent's mailing address and contact information: [ADDRESS / CONTACT]
Prospective adoptive parent(s): [NAMES]
Placement agency, if any: [AGENCY NAME / CONTACT]
Adoption court and case number, if assigned: [COUNTY / CASE NUMBER]

☐ Agency-supervised placement
☐ Stepparent adoption

Other parent or guardian whose consent or notice may be required: [NAME / STATUS]. Record how that requirement was addressed: [DETAILS / DOCUMENTS]. If the consenting parent is an unmarried minor, arrange the additional consent and consultation opportunity required by § 259.24, subd. 2. If the child is over 14, arrange the child's separate written consent under subd. 3.

2. PARENT'S CONSENT

I am the parent identified above. I consent voluntarily to the adoption of the child by the prospective adoptive parent(s) identified above. I have had an opportunity to ask questions about the adoption and the effect and withdrawal of my consent. No one has promised me that this document alone will end my parental rights.

Child's birth date: [__/__/____]
Date placed in prospective adoptive home, if applicable: [__/__/____]
Date of signing: [__/__/____]

Under § 259.24, subd. 2a, a required consent is executed no sooner than 72 hours after birth and no later than 60 days after placement in a prospective adoptive home. Have the agency or attorney confirm how that timing applies to this adoption before signing.

3. NOTICE OF WITHDRAWAL RIGHTS

Under § 259.24, subd. 6a, a parent may withdraw consent for any reason within ten working days after execution and acknowledgment. Written withdrawal must be received by the tenth working day by the agency to which the child was surrendered, the agency supervising the adoptive placement, or, for a stepparent adoption or an adoption without agency placement or supervision, the district court where the adopting stepparent or parent resides. Confirm the proper recipient and keep proof of timely receipt. On the following day, consent becomes irrevocable except by court order after written findings that it was obtained by fraud.

Recipient for withdrawal notice: [AGENCY OR DISTRICT COURT / ADDRESS]
Execution and acknowledgment date: [__/__/____]
Calculated tenth working day (confirm with counsel): [__/__/____]

4. REQUIRED PARENT NOTICE

Print the following statutory notice in all capital letters at least one-eighth inch high before the parent signs. Minn. Stat. § 259.24, subd. 5. A browser or PDF export may change the printed size; inspect the final paper copy.

THE AGENCY RESPONSIBLE FOR SUPERVISING THE ADOPTIVE PLACEMENT OF THE CHILD WILL SUBMIT YOUR CONSENT TO ADOPTION TO THE COURT. IF YOU ARE CONSENTING TO ADOPTION BY THE CHILD'S STEPPARENT, THE CONSENT WILL BE SUBMITTED TO THE COURT BY THE PETITIONER IN YOUR CHILD'S ADOPTION. THE CONSENT ITSELF DOES NOT TERMINATE YOUR PARENTAL RIGHTS. PARENTAL RIGHTS TO A CHILD MAY BE TERMINATED ONLY BY AN ADOPTION DECREE OR BY A COURT ORDER TERMINATING PARENTAL RIGHTS. UNLESS THE CHILD IS ADOPTED OR YOUR PARENTAL RIGHTS ARE TERMINATED, YOU MAY BE ASKED TO SUPPORT THE CHILD.

5. EXECUTION, TWO WITNESSES, AND ACKNOWLEDGMENT

I have read this consent, including the withdrawal and required parent notices, and sign it voluntarily.

Parent signature: ______________________________ Date: [__/__/____]
Printed name: [PARENT NAME]

Witness 1 signature: __________________________ Date: [__/__/____]
Printed name and address: [NAME / ADDRESS]

Witness 2 signature: __________________________ Date: [__/__/____]
Printed name and address: [NAME / ADDRESS]

Acknowledgment

State of Minnesota, County of [COUNTY]. Acknowledged before me on [__/__/____] by [PARENT NAME].

Notary public signature: ________________________
Commission expiration: [__/__/____]

6. FILING CHECK

☐ The agency or stepparent petitioner has confirmed who submits this consent to the court.
☐ All required consents and notices have been addressed.
☐ The signed consent will be filed before the adoption matter is heard, as § 259.24, subd. 5 requires.
☐ The executed paper copy shows the required notice at the minimum printed height.

SOURCES AND REFERENCES

• Minn. Stat. § 259.24: https://www.revisor.mn.gov/statutes/cite/259.24
• Minn. Stat. § 259.47, subd. 7: https://www.revisor.mn.gov/statutes/cite/259.47