DISCLAIMER – READ BEFORE USE
This template is provided for informational purposes only and does not constitute legal advice, nor does it create an attorney-client relationship. New York adoption law is complex, fact-specific, and subject to frequent revision. Practitioners must verify all statutory references, local court rules, and agency regulations in effect on the execution date, and tailor this document to the particular circumstances of each matter. Consult qualified counsel before using or relying on this form.
NEW YORK PARENTAL CONSENT TO ADOPTION
(Private-Placement / Extra-Judicial Consent under N.Y. Dom. Rel. Law § 115-b)
Effective Date: [DATE]
County & State of Execution: [___] County, New York
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Voluntary Consent & Relinquishment
3.2 Timing & Execution Requirements
3.3 Revocation Rights
3.4 Counseling Acknowledgment - Representations & Warranties
- Covenants
- Default & Remedies
- Risk Allocation (Not Applicable)
- Dispute Resolution
- General Provisions
- Execution Block
- Notary Acknowledgment
[// GUIDANCE: Sections 4–8 are included to mirror the requested architecture; some items are inapplicable for an adoption consent and are labeled accordingly.]
1. DOCUMENT HEADER
This Parental Consent to Adoption (the “Consent”) is made by [LEGAL NAME OF PARENT/GUARDIAN] (“Consenting Parent”), concerning the adoption of the minor child identified below (the “Child”) by [PROSPECTIVE ADOPTIVE PARENT(S) LEGAL NAME(S)] (“Prospective Adoptive Parent(s)”), in accordance with the New York Domestic Relations Law (“DRL”), Article 7, and related statutes, regulations, and court rules.
A. Child’s Full Legal Name: [NAME]
B. Child’s Date of Birth: [MM/DD/YYYY]
C. Child’s Place of Birth: [HOSPITAL / CITY / COUNTY / STATE]
Recitals
1. Consenting Parent is the [mother / father / legal guardian] of the Child and possesses the legal authority to execute this Consent.
2. Consenting Parent desires to permanently and irrevocably relinquish all parental rights to the Child (subject to the statutory revocation period set forth below) so that the Child may be adopted by the Prospective Adoptive Parent(s).
3. No payments or consideration have been made or promised to Consenting Parent except those permitted under DRL § 115-b(3)(a).
2. DEFINITIONS
“Child” – The minor identified in Section 1(A)–(C).
“Consenting Parent” – The person executing this Consent as parent or legal guardian of the Child.
“Court” – The New York Family Court or Surrogate’s Court having jurisdiction over the adoption proceeding.
“Execution Date” – The calendar date on which Consenting Parent signs this document before the authorized official.
“Prospective Adoptive Parent(s)” – The individual(s) seeking to adopt the Child.
“Revocation Period” – The statutory period during which Consenting Parent may withdraw this Consent as detailed in Section 3.3.
3. OPERATIVE PROVISIONS
3.1 Voluntary Consent & Relinquishment
(a) Consenting Parent hereby voluntarily, knowingly, and intentionally:
(i) Consents to the adoption of the Child by the Prospective Adoptive Parent(s); and
(ii) Relinquishes all parental rights, obligations, and responsibilities with respect to the Child, subject only to the Revocation Period set forth in Section 3.3.
(b) This Consent is executed without duress, coercion, or undue influence, and after having been informed of the right to independent counsel.
3.2 Timing & Execution Requirements
(a) Pursuant to DRL § 115-b(3), this Consent is being executed no sooner than three (3) days after the Child’s birth and before a judge, referee, or other authorized judicial officer in the county stated above.
(b) The executing official shall certify compliance with DRL § 115-b and ensure that Consenting Parent is advised of:
(i) the right to legal counsel;
(ii) the consequences of signing; and
(iii) the right to obtain supportive counseling.
[// GUIDANCE: For agency surrenders under Social Services Law § 384 or DRL § 384-b, different timing rules apply. Replace Section 3.2 accordingly if this is an agency placement.]
3.3 Revocation Rights
(a) Consenting Parent may revoke this Consent for any reason by delivering written notice to the Court within forty-five (45) days after the Execution Date. DRL § 115-b(4)(a).
(b) After the 45-day period, withdrawal is permissible only upon a showing of fraud, duress, or coercion and within 60 days of execution. DRL § 115-b(4)(b).
(c) Notice of revocation must be filed with the Court and served on:
(i) Prospective Adoptive Parent(s) or their attorney; and
(ii) Any adoption service provider involved in placement.
3.4 Counseling Acknowledgment
Consenting Parent acknowledges that:
(a) Counseling services regarding the emotional and legal aspects of adoption have been offered and explained.
(b) Consenting Parent has [accepted / declined] such counseling.
(c) Declining counseling does not affect the validity of this Consent.
4. REPRESENTATIONS & WARRANTIES
Consenting Parent represents and warrants that:
4.1 Parentage & Authority – Consenting Parent is the Child’s lawful [mother / father / guardian] and holds sole authority to consent. No other person’s consent is required under DRL § 111.
4.2 Absence of Consideration – Consenting Parent has neither received nor been promised any compensation or thing of value in violation of DRL § 123.
4.3 No Pending Litigation – There is no pending custody or parentage litigation concerning the Child, except: [INSERT “none” OR DETAILS].
4.4 Accuracy of Information – All information provided herein is true, complete, and accurate to the best of Consenting Parent’s knowledge.
Survival – The representations in Section 4 survive execution and, to the extent permitted by law, finalization of the adoption.
5. COVENANTS
5.1 Cooperation – Consenting Parent shall execute any additional documents reasonably requested by the Court to perfect the adoption.
5.2 No Interference – After expiration of the Revocation Period, Consenting Parent shall not contest the adoption or seek custody or visitation, except as allowed by statute.
5.3 Confidentiality – Consenting Parent shall keep confidential any identifying information of Prospective Adoptive Parent(s) obtained through the adoption process, consistent with DRL § 114.
6. DEFAULT & REMEDIES
6.1 Default – A “Default” occurs if Consenting Parent attempts to withdraw this Consent outside the Revocation Period without statutory basis.
6.2 Remedies – Upon Default, Prospective Adoptive Parent(s) may seek:
(a) Dismissal of any petition to withdraw consent; and
(b) Specific enforcement of this Consent through the Court’s equitable powers.
6.3 Attorneys’ Fees – The Court may award reasonable attorneys’ fees to the prevailing party in any contested revocation proceeding, as justice requires (DRL § 115-b(8)).
[// GUIDANCE: Remedies are subject to Family Court discretion; include local practice references as appropriate.]
7. RISK ALLOCATION
Indemnification, limitation of liability, and insurance provisions are not applicable to this Consent, consistent with the Metadata supplied.
8. DISPUTE RESOLUTION
8.1 Governing Law – This Consent is governed by “state_adoption_law,” understood to mean the New York Domestic Relations Law and related statutes.
8.2 Forum – Exclusive jurisdiction lies with the “state_family_court,” i.e., the Family Court (or Surrogate’s Court where the adoption petition is filed) within the State of New York.
8.3 Arbitration – “not_available.” All disputes shall be resolved by the Court.
8.4 Jury Waiver – “no_jury_family_court.” Jury trials are not available in NY adoption matters.
8.5 Injunctive Relief – The Court retains authority to issue orders ensuring the Child’s “permanent_placement” and best interests.
9. GENERAL PROVISIONS
9.1 Entire Agreement – This Consent constitutes the entire agreement between the parties on the subject matter and supersedes prior understandings.
9.2 Amendment – No modification is effective unless in writing and executed with the same formalities as this Consent.
9.3 Severability – If any provision is held invalid, the remainder shall be enforced to the fullest extent permitted by law.
9.4 Counterparts – This Consent may be executed in counterparts, each of which is deemed an original.
9.5 Electronic Signatures – Permitted to the extent allowed by N.Y. Tech. Law § 304, but not in place of the statutory in-person acknowledgment requirements of DRL § 115-b.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, Consenting Parent executes this Parental Consent to Adoption on the Effective Date stated above.
[LEGAL NAME OF CONSENTING PARENT]
Consenting Parent
Date Signed: ________
[// GUIDANCE: If two parents/guardians are executing, duplicate the signature block.]
11. NOTARY / JUDICIAL ACKNOWLEDGMENT
State of New York )
County of ______ ) ss.:
On the ___ day of ____, 20__, before me, the undersigned [Judge / Judicial Hearing Officer / Referee / Notary Public], personally appeared [NAME OF CONSENTING PARENT], personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this Consent, and acknowledged to me that they executed the same voluntarily for the purposes therein stated. I have fully explained to the Consenting Parent their rights and the legal consequences of this Consent, as required by DRL § 115-b.
[Signature of Authorized Official]
[Print Name]
Title: ____
My Commission Expires: ______
[// GUIDANCE: File the executed original with the adoption petition. Serve copies as required by DRL § 115-b(6). Attach any statutorily mandated disclosure schedules (e.g., medical/heritage information) as separate exhibits.]