Adoption Consent Form - Nebraska

NEBRASKA PARENTAL CONSENT AND RELINQUISHMENT FOR ADOPTION

This is a preparation draft for one consenting parent. It is not a private
contract, an adoption decree, or a substitute for case-specific advice and
court or agency instructions. Counsel must select exactly one route below and
confirm every person whose consent is required before this form is signed.

1. REQUIRED USE GATES

• ☐ The child has already been born.

• ☐ The signature will occur at least forty-eight hours after the child's
  birth, as required by Neb. Rev. Stat. § 43-104(2).

• ☐ Counsel has determined who must consent under § 43-104, including whether
  the child is over fourteen and whether another parent, an acknowledged or
  adjudicated father, or a putative father has rights requiring separate
  action.

• ☐ Counsel has determined whether the Nebraska Indian Child Welfare Act or
  tribal-customary-adoption provisions apply.

• ☐ No blank revocation period, private remedy, fee award, or filing deadline
  has been inserted into this form without current Nebraska authority and
  case-specific legal review.

Attorney confirming gates: [________________________________]

Date confirmed: [__/__/____]

2. SELECT EXACTLY ONE ROUTE

Route A — Private Adoption

• ☐ The child is not being relinquished to the Nebraska Department of Health
  and Human Services or a licensed child placement agency.

• ☐ The consenting parent directly consents to adoption by the prospective
  adoptive parent or parents identified below.

• ☐ The independent-counsel and counseling-offer records in Section 6 are
  complete.

Route B — Agency or Department Relinquishment

• ☐ The child is being relinquished to:
  ☐ Nebraska Department of Health and Human Services; or
  ☐ [LICENSED CHILD PLACEMENT AGENCY].

• ☐ The agency or department will complete the separate written acceptance in
  Section 10. An unsigned acceptance must not be treated as an acceptance of
  full responsibility under Neb. Rev. Stat. § 43-106.01.

Selected route: ☐ Route A ☐ Route B

3. CHILD AND SIGNER INFORMATION

Section 43-104(8) provides that a relinquishment or consent is not invalid
merely because the relinquishing person is a minor. Counsel must still address
capacity, voluntariness, and all case-specific safeguards.

4. PROSPECTIVE ADOPTIVE PARENT INFORMATION

Complete for Route A and when known for Route B.

5. COURT-FILING INFORMATION

Neb. Rev. Stat. § 43-104(1) requires the written consent to be filed in one of
the county courts identified by that section. Counsel must select the correct
statutory basis; this form does not create exclusive venue in a juvenile
division.

• ☐ County court of the county where the person or persons desiring to adopt
  reside.

• ☐ County court in which the juvenile court having jurisdiction over the
  child's custody is located.

Court: County Court of [________________] County, Nebraska

Related juvenile case, if any: [________________________________]

Adoption case number, if assigned: [________________________________]

6. COUNSEL AND COUNSELING RECORD

6.1 Independent Counsel — Route A Only

For a private adoption that does not involve relinquishment to the state or a
licensed child placement agency, § 43-104(9)(a) provides for counsel chosen by
the relinquishing parent, independent from adoptive-parent counsel and at the
adoptive parent or parents' expense, before execution unless specifically
waived in writing.

Select one:

• ☐ I selected and received independent legal counsel from
  [ATTORNEY NAME], Nebraska Bar No. [________].

• ☐ I specifically waive in writing the independent counsel described above.
  I understand that the prospective adoptive parent or parents' attorney does
  not represent me.

• ☐ Not applicable because Route B was selected.

6.2 Professional Counseling Offer

For a private adoption or an adoption involving relinquishment to a licensed
child placement agency other than the state, § 43-104(9)(b) requires that the
parent be offered, at the adoptive parent or parents' or agency's expense, at
least three hours of professional counseling before signing. The consent must
state whether counseling was received or declined.

Select one:

• ☐ I received at least three hours of professional counseling before signing.
  Provider: [________________] Dates: [________________]

• ☐ I was offered at least three hours of professional counseling before
  signing and declined it.

• ☐ Not applicable because the relinquishment is to the Nebraska Department of
  Health and Human Services.

7. PARENT'S CONSENT AND RELINQUISHMENT

I, [CONSENTING PARENT NAME], state as follows:

1. I am the [LEGAL RELATIONSHIP] of [CHILD NAME].

2. The child was born on [DATE] at [TIME]. I am signing this instrument on
   [DATE] at [TIME], at least forty-eight hours after the child's birth.

3. I have reviewed the route selected in Section 2 and understand that the
   private-adoption and agency-relinquishment routes have different legal
   effects and procedures.

4. If Route A is selected, I voluntarily consent to the child's adoption by
   the prospective adoptive parent or parents identified in Section 4.

5. If Route B is selected, I voluntarily relinquish the child to the department
   or licensed child placement agency identified in Section 2 and request its
   separate written acceptance of full responsibility.

6. I understand that this one-parent instrument does not establish that every
   consent, notice, objection, waiver, court finding, or other requirement for
   the adoption has been satisfied.

7. I have disclosed to my attorney all persons who may claim parental rights
   and all known tribal or Native American ancestry of the child or either
   parent.

8. I sign voluntarily and without fraud, duress, coercion, or an undisclosed
   promise of payment.

8. ROUTE-SPECIFIC EFFECT AND WITHDRAWAL WARNING

For Route B, Neb. Rev. Stat. § 43-106.01 provides that when the child has been
relinquished by written instrument to the department or a licensed child
placement agency and that recipient has accepted full responsibility in
writing, the relinquishing person is relieved of parental duties and
responsibilities and has no rights over the child; the statute does not impair
the child's inheritance right.

This form deliberately states no universal fixed revocation period. The legal
effect of an attempted withdrawal depends on the selected route, timing,
acceptance, court proceedings, and current law. Obtain immediate advice from
independent Nebraska adoption counsel before attempting or responding to a
withdrawal.

9. EXECUTION, WITNESS, AND ACKNOWLEDGMENT

Neb. Rev. Stat. § 43-106 requires this instrument to be acknowledged before an
officer authorized to acknowledge deeds in Nebraska and signed in the presence
of at least one witness in addition to that officer.

Consenting Parent

Signature: __________________________________________

Printed name: [________________________________]

Signed on: [__/__/____] at [________] ☐ a.m. ☐ p.m.

Location: [CITY], Nebraska

Additional Witness

I witnessed the consenting parent sign this instrument.

Witness signature: ___________________________________

Printed name: [________________________________]

Address: [________________________________]

Date and time witnessed: [________________________________]

Acknowledgment

State of Nebraska )

County of [________________] ) ss.

This instrument was acknowledged before me on [__/__/____] by
[CONSENTING PARENT NAME].

Signature of acknowledgment officer: ______________________________

Printed name and title: [________________________________]

Commission expiration, if applicable: [________________________________]

Official seal:

10. WRITTEN ACCEPTANCE OF FULL RESPONSIBILITY — ROUTE B ONLY

Do not complete for Route A.

The undersigned, acting for ☐ the Nebraska Department of Health and Human
Services or ☐ [LICENSED CHILD PLACEMENT AGENCY], accepts full responsibility
for [CHILD NAME] in writing under Neb. Rev. Stat. § 43-106.01.

Authorized representative signature: ______________________________

Printed name and title: [________________________________]

Agency or department: [________________________________]

Date and time accepted: [________________________________]

11. FINAL COUNSEL REVIEW

• ☐ Correct route selected and inconsistent language removed.
• ☐ Forty-eight-hour calculation independently checked.
• ☐ Every required consent and parentage issue reviewed.
• ☐ Independent-counsel provision or written waiver completed when applicable.
• ☐ Counseling receipt or declination stated when applicable.

• ☐ One additional witness and the acknowledgment officer were both present as
  required.

• ☐ Correct county court and any juvenile proceeding confirmed.

• ☐ Agency or department acceptance completed only for Route B.
• ☐ Current local filing instructions and any required attachments confirmed.

SOURCES AND REFERENCES

• Neb. Rev. Stat. § 43-104 — consent, timing, filing, counsel, and counseling (official Nebraska Legislature)
• Neb. Rev. Stat. § 43-106 — acknowledgment and witness (official Nebraska Legislature)
• Neb. Rev. Stat. § 43-106.01 — agency acceptance and effect (official Nebraska Legislature)