CONSENT TO ADOPTION
(Commonwealth of Pennsylvania)
[// GUIDANCE: This template is designed for use by Pennsylvania-licensed practitioners. Review 23 Pa. Cons. Stat. Ann. §§ 2503-2505 & 2711 in full before filing. Modify bracketed text and choose alternatives that fit the specific facts. Remove all guidance comments prior to execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation (Reserved)
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Consent of [Birth Mother / Birth Father / Legal Guardian] to the Adoption of [Child’s Legal Name]
1.2 Parties.
a. “Consenting Party”: [Full Legal Name], currently residing at [Street Address, City, County, PA ZIP].
b. “Child”: [Full Legal Name of Child], born [Date of Birth] in [Place of Birth].
c. “Prospective Adoptive Parent(s)”: [Name(s)].
1.3 Recitals.
WHEREAS, the Consenting Party is a [birth parent/legal guardian] of the Child; and
WHEREAS, the Consenting Party desires voluntarily and unconditionally to consent to the adoption of the Child pursuant to 23 Pa. Cons. Stat. Ann. § 2711;
NOW, THEREFORE, in consideration of the mutual promises herein and intending to be legally bound, the parties agree as follows.
1.4 Effective Date. This Consent becomes effective on the date acknowledged before a notary public in the Commonwealth of Pennsylvania, subject to statutory revocation rights (the “Effective Date”).
2. DEFINITIONS
For purposes of this Consent, the following terms have the meanings set forth below. Capitalized terms used but not defined have their ordinary legal meaning.
“Adoption Proceeding” – The action filed in the [County] Court of Common Pleas, Orphans’ Court Division, seeking termination of parental rights and finalization of the Child’s adoption.
“Commonwealth” – The Commonwealth of Pennsylvania.
“Family Court” – The Orphans’ Court Division of the Court of Common Pleas of [County], Pennsylvania.
“Revocation Period” – The statutory period during which this Consent may be revoked, being thirty (30) days after the later of (i) the date the Consent is executed or (ii) the date it is filed with the court, pursuant to 23 Pa. Cons. Stat. Ann. § 2711(c)(1).
3. OPERATIVE PROVISIONS
3.1 Grant of Consent.
Pursuant to 23 Pa. Cons. Stat. Ann. § 2711(d), the Consenting Party hereby states:
- “I hereby voluntarily and unconditionally consent to the adoption of the above-named Child.”
- “I understand that by signing this consent I indicate my intent to permanently give up all rights to the Child.”
- “I understand that the Child will be placed for adoption.”
- “I understand that I may revoke this consent to adoption at any time within the Revocation Period by delivering written notice of revocation to [Name and Address of Clerk of the Orphans’ Court or Agency, as applicable].”
3.2 Statutory Timing Compliance.
a. If the Consenting Party is the Child’s birth mother, this Consent shall not be executed until at least seventy-two (72) hours have elapsed since the Child’s birth, as required by 23 Pa. Cons. Stat. Ann. § 2711(a)(5).
b. A father or putative father may execute this Consent at any time after the Child’s birth.
[// GUIDANCE: Delete subsection (b) if not applicable, and verify timing under current law.]
3.3 Counseling Acknowledgment.
The Consenting Party acknowledges receipt, prior to execution of this Consent, of written notice of the right to no-cost adoption-related counseling in accordance with 23 Pa. Cons. Stat. Ann. §§ 2503-2505, and either:
• has elected to receive such counseling; or
• knowingly waives that right.
Select one: [ELECTS / WAIVES] counseling.
3.4 Conditions Precedent.
This Consent is conditioned upon:
a. Proper notarization and witnessing as required by Pennsylvania law.
b. Filing with the Family Court within [__] days after execution.
Failure of any condition does not affect the Consenting Party’s statutory rights to revocation.
4. REPRESENTATIONS & WARRANTIES
The Consenting Party hereby represents and warrants that:
a. Age & Capacity – The Consenting Party is at least 18 years old and has legal capacity to execute this Consent.
b. Sole/Shared Legal Custody – The Consenting Party possesses the legal right to consent to the Child’s adoption.
c. Voluntariness – Execution of this Consent is wholly voluntary, free of coercion, duress, or undue influence.
d. Completeness & Accuracy – All information provided herein is true, complete, and accurate to the best of the Consenting Party’s knowledge.
e. No Pending Litigation – No other court proceeding seeks to determine custody or terminate parental rights regarding the Child, except as disclosed in Schedule A (attach if applicable).
These representations survive the execution of this Consent through the expiration of the Revocation Period.
5. COVENANTS & RESTRICTIONS
a. Cooperation – The Consenting Party shall execute and deliver such further instruments and documents as may be reasonably necessary to effectuate the Child’s adoption.
b. Contact – Except as otherwise agreed in writing with the Prospective Adoptive Parent(s) or ordered by the Family Court, the Consenting Party shall not contact the Child after entry of the final adoption decree.
c. Confidentiality – The Consenting Party shall keep confidential all identifying information concerning the Prospective Adoptive Parent(s), except as required by law.
6. DEFAULT & REMEDIES
6.1 Statutory Revocation. The sole remedy for wrongful inducement or other challenge to this Consent prior to final adoption is revocation within the Revocation Period pursuant to 23 Pa. Cons. Stat. Ann. § 2711(c).
6.2 Post-Revocation Period. After the Revocation Period expires, this Consent becomes irrevocable except upon proof of fraud or duress as provided by applicable law.
6.3 Attorneys’ Fees. The prevailing party in any action to enforce or set aside this Consent shall be entitled to reasonable attorneys’ fees and costs as determined by the Family Court.
7. RISK ALLOCATION (Reserved)
[// GUIDANCE: Indemnification and liability cap provisions are intentionally omitted per metadata.]
8. DISPUTE RESOLUTION
a. Governing Law – This Consent shall be governed by and construed in accordance with the laws of the Commonwealth.
b. Forum Selection – Exclusive jurisdiction and venue lie in the [County] Court of Common Pleas, Orphans’ Court Division.
c. Arbitration – Not applicable.
d. Jury Waiver – Jury trials are unavailable in the Orphans’ Court Division.
e. Injunctive Relief – The Family Court retains authority to issue any injunctive orders necessary to protect the Child’s welfare and effectuate permanent placement.
9. GENERAL PROVISIONS
a. Entire Agreement – This document constitutes the entire agreement of the parties regarding the subject matter and supersedes all prior oral or written statements.
b. Amendments – Any amendment must be in writing, signed by the Consenting Party, and acknowledged with the same formalities as this Consent.
c. Severability – If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force to the extent permitted by law.
d. Counterparts; Electronic Signatures – This Consent may be executed in counterparts, and signatures transmitted electronically shall be deemed originals.
e. Successors & Assigns – This Consent binds the Consenting Party and inures to the benefit of the Child, the Prospective Adoptive Parent(s), and their respective successors.
10. EXECUTION BLOCK
Executed and agreed as of the Effective Date set forth below.
CONSENTING PARTY
[Full Legal Name]
Date: ___ / ___ / 20___
WITNESSES (two required)
1. _____ Date: ___ / ___ / 20
2. _____ Date: ___ / ___ / 20
NOTARIZATION
Commonwealth of Pennsylvania )
) ss.:
County of [County] )
On this ___ day of _, 20, before me, the undersigned notary public, personally appeared [Name of Consenting Party], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
My Commission Expires: _____
[// GUIDANCE: File the executed original with the Clerk of the Orphans’ Court within the statutory timeframe. Retain a conformed copy in the client’s file. Verify local county rules for additional filing or notice requirements.]