Adoption Consent Form

TEXAS ADOPTION CONSENT AND RELINQUISHMENT PREPARATION PACKET

Do not use one generic “consent” for every signer. Texas separates a parent's affidavit of voluntary relinquishment under Tex. Fam. Code § 161.103 from the managing conservator's consent and a child-age-12-or-older consent under § 162.010. Select and complete only the parts that fit the case.

TABLE OF CONTENTS

1. Route and case information
2. Parent's affidavit of voluntary relinquishment
3. Affidavit execution and copy receipt
4. Revocation statement, when legally available
5. Managing conservator consent
6. Child consent for a child age 12 or older
7. Health-history and filing checklist
8. Sources and references

1. ROUTE AND CASE INFORMATION

A. Select the instrument being prepared

☐ Part 2 — Parent's affidavit of voluntary relinquishment. Use for a parent relinquishing parental rights under § 161.103. The affidavit supports a termination proceeding; signing alone does not terminate parental rights. The court must still find a statutory ground and that termination is in the child's best interest.

☐ Part 5 — Managing conservator consent to adoption. Unless the managing conservator is the petitioner, written consent must be filed under § 162.010(a), subject to the court's good-cause waiver authority.

☐ Part 6 — Child consent. A child age 12 or older must consent in writing or in court unless the court waives consent in the child's best interest under § 162.010(c).

☐ Stepparent route. If a parent is the petitioner's spouse, that parent joins the adoption petition and no further consent from that parent is required under § 162.010(b).

B. Case and child information

C. Adoption prerequisite screen

Before relying on this packet, counsel must identify the applicable § 162.001 route:

☐ The parent-child relationship as to each living parent has been terminated, or termination is joined with adoption.

☐ A nonterminated parent is the petitioner's spouse and the case is a stepparent adoption.

☐ Another specific § 162.001 route applies and is described here: [________________________________].

☐ Alleged-father, paternity-registry, notice, service, and termination issues have been separately reviewed.

2. PARENT'S AFFIDAVIT OF VOLUNTARY RELINQUISHMENT

AFFIDAVIT OF VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS

I, [PARENT'S FULL LEGAL NAME], being duly sworn, state:

1. Parent information

The signing parent may be a minor. Section 161.103(a)(1) requires the signature of the parent whose rights are being relinquished, whether or not the parent is a minor.

2. Child information

3. Guardians, if any

☐ The child has no guardian of the person or estate.

☐ The child has the following guardian(s):

4. Court-ordered support

☐ I am not presently obligated by court order to make support payments for the child.

☐ I am presently obligated by court order to make support payments for the child. Court/cause number and payment terms: [________________________________].

5. Property owned or possessed by the child

☐ The child owns or possesses no property requiring disclosure.

6. Best interest

I allege that termination of my parent-child relationship with the child is in the child's best interest. I understand the court must make its own best-interest finding before terminating parental rights.

7. Other parent

Select one and complete it accurately:

☐ The other parent's full name, county of residence, and address are: [________________________________].

☐ The other parent's rights were terminated by death or court order. Details: [________________________________].

☐ The child has no presumed father.

8. Information about parental rights and duties

I have been informed of the parental rights and duties affected by this relinquishment. Questions about independent counsel, appointed counsel, interpreters, or accommodations must be resolved for this specific case before signing; this packet does not state that appointed counsel is available in every private adoption.

9. Revocability selection

Select exactly one route after advice from Texas adoption counsel:

☐ DFPS or licensed-agency designation. I designate DFPS or a licensed child-placing agency as managing conservator. Under § 161.103(e), this relinquishment is irrevocable.

☐ Private designation — revocable. This relinquishment is revocable. The following warning must remain boldfaced:

THIS RELINQUISHMENT IS REVOCABLE ONLY IF THE REVOCATION IS MADE BEFORE THE 11TH DAY AFTER THE DATE THIS AFFIDAVIT IS EXECUTED.

☐ Private designation — temporarily irrevocable. This relinquishment is irrevocable for [____] days after execution. The stated period may not exceed 60 days.

Do not leave revocability unstated. If an affidavit fails to state that relinquishment is irrevocable for a stated time, § 161.1035 makes it revocable only before the 11th day after execution and irrevocable on or after that day.

10. Revocation recipient, if the relinquishment is revocable

11. Designated managing conservator

I designate the following qualified person or entity to serve as managing conservator of the child:

☐ Prospective adoptive parent: [________________________________]

☐ Department of Family and Protective Services, which has consented in writing to the designation

☐ Licensed child-placing agency: [________________________________]

Address: [________________________________]

I understand that an irrevocable or unrevoked affidavit gives the designated managing conservator the interim rights stated in § 161.104 until a court modifies or terminates them.

12. Optional waiver and placement consent

☐ I waive issuance or service of process in a termination suit or a termination suit joined with adoption, as permitted by § 161.103(c)(1).

☐ I consent to placement of the child for adoption by DFPS or the following licensed child-placing agency, as permitted by § 161.103(c)(2): [________________________________].

13. Required medical history report

I have prepared or will complete the birth-parent medical history information required by § 161.1031 for use in the health, social, educational, and genetic history report.

14. No conditional post-termination contact term

This affidavit does not make limited post-termination contact a condition of relinquishment. Section 161.103(h) prohibits that condition from appearing in the affidavit.

3. AFFIDAVIT EXECUTION AND COPY RECEIPT

A. Forty-eight-hour timing check

Section 161.103(a)(1) prohibits signing before 48 hours after birth.

☐ At least 48 hours elapsed between birth and signature.

B. Parent signature

I declare that I read this affidavit, that the completed statements are true and correct, and that I sign voluntarily under oath.

Parent signature: _______________________________________

Printed name: [________________________________]

Date and time signed: [__/__/____] at [____] ☐ a.m. ☐ p.m.

C. Two credible witnesses

D. Verification before a person authorized to take oaths

STATE OF TEXAS

COUNTY OF [________________________________]

Sworn to and subscribed before me on [__/__/____] at [____] ☐ a.m. ☐ p.m. by [PARENT'S FULL LEGAL NAME].

_______________________________________

Notary Public or Other Person Authorized to Take Oaths

Printed name: [________________________________]

Commission expires, if applicable: [__/__/____]

E. Copy provided at signing

Section 161.103(d) requires a copy at the time of signing.

I acknowledge that I received a complete copy of the signed affidavit at the time I signed it.

Parent initials: [____] Date/time copy received: [__/__/____] at [____] ☐ a.m. ☐ p.m.

4. REVOCATION STATEMENT, WHEN LEGALLY AVAILABLE

Use this part only if the executed affidavit is revocable and the statutory time has not expired. Do not use it to revoke an affidavit that is irrevocable because it designates DFPS or a licensed child-placing agency, or during a valid stated irrevocability period.

STATEMENT REVOKING RELINQUISHMENT

I, [PARENT'S FULL LEGAL NAME], revoke the affidavit of voluntary relinquishment of parental rights that I executed on [__/__/____] concerning [CHILD'S FULL LEGAL NAME].

Parent signature: _______________________________________

Date and time signed: [__/__/____] at [____] ☐ a.m. ☐ p.m.

Two credible witnesses to revocation

Verification of revocation

STATE OF TEXAS

COUNTY OF [________________________________]

Sworn to and subscribed before me on [__/__/____] by [PARENT'S FULL LEGAL NAME].

_______________________________________

Notary Public or Other Person Authorized to Take Oaths

Delivery and court-filing log

5. MANAGING CONSERVATOR CONSENT TO ADOPTION

Use this part only for the written consent required by § 162.010(a). It is not a substitute for a parent's § 161.103 affidavit.

I, [MANAGING CONSERVATOR'S FULL LEGAL NAME], am the child's current managing conservator and consent to the adoption of [CHILD'S FULL LEGAL NAME] by [PROSPECTIVE ADOPTIVE PARENT(S)].

☐ I am not the adoption petitioner, so this written consent will be filed.

☐ I am the adoption petitioner; counsel has determined whether a separate consent is unnecessary under § 162.010(a).

I understand that a consent required by § 162.010 may be revoked at any time before the adoption order by filing a signed revocation under § 162.011.

Managing conservator signature: _______________________________________

Printed name: [________________________________]

Date: [__/__/____]

6. CHILD CONSENT FOR A CHILD AGE 12 OR OLDER

Under § 162.010(c), a child age 12 or older must consent in writing or in court unless the court waives consent in the child's best interest.

☐ The child is under age 12; this part is not required.

☐ The child will consent in court.

☐ The child uses the written consent below.

I, [CHILD'S FULL LEGAL NAME], am [____] years old. I consent to my adoption by [PROSPECTIVE ADOPTIVE PARENT(S)].

Child signature: _______________________________________

Date: [__/__/____]

☐ Counsel will request a court waiver of child consent based on the child's best interest. Basis: [________________________________].

7. HEALTH-HISTORY AND FILING CHECKLIST

A. Birth-parent medical history

Section 161.1031 requires a parent who signs a § 161.103 affidavit regarding a biological child to prepare a medical history report addressing the parent's and ancestors' medical history.

☐ Birth parent completed the current Texas HSEGH Addendum.

☐ Counsel or the placing entity coordinated the remaining HSEGH report required by §§ 162.005-.008.

B. HSEGH route

Sections 162.005 and 162.008 do not apply to an adoption by the child's grandparent, aunt or uncle by birth, marriage, or prior adoption, or stepparent.

☐ Relative/stepparent exception applies: [________________________________].

☐ Non-relative private adoption without an agency. The current DSHS instructions require the attorney to submit the HSEGH Form, birth-parent Addendum, and Information Cover Sheet to Vital Statistics before consummation. The court may waive the report when the statutory insufficient-information condition is met.

☐ Licensed-agency or DFPS route. The responsible placing entity will prepare, distribute, supplement, and retain the report under the applicable statutory provisions.

C. Final statutory checklist

☐ The parent signed the relinquishment after birth and at least 48 hours after birth.

☐ Two credible witnesses signed.

☐ The affidavit was verified before a person authorized to take oaths.

☐ Every item required by § 161.103(b) is completed.

☐ Revocability language matches the selected managing-conservator route and any stated irrevocability period does not exceed 60 days.

☐ A complete copy was given to the parent at signing.

☐ The § 161.1031 medical history report was prepared.

☐ Any managing conservator consent required by § 162.010(a) will be filed.

☐ Any child age 12 or older will consent in writing or in court, or counsel will request a best-interest waiver.

☐ The termination/adoption pleadings request the separate best-interest findings required by §§ 161.001 and 162.016.

☐ Counsel separately reviewed the adoption petition, standing, notice and service, paternity-registry issues, adoption evaluation, criminal history, placement regulation, and any special federal or tribal-law issue; those matters are outside this packet.

D. Terms intentionally excluded

Do not add private-contract default, specific-performance, prevailing-party-fee, arbitration, jury-waiver, indemnity, liability-cap, force-majeure, assignment, or electronic-signature clauses to this statutory affidavit packet. Those clauses do not substitute for the Family Code's execution, revocation, termination, consent, and court-order requirements.

8. SOURCES AND REFERENCES

• Texas Family Code Chapter 161 — https://tcss.legis.texas.gov/resources/FA/htm/FA.161.htm
• Texas Family Code Chapter 162 — https://tcss.legis.texas.gov/resources/FA/htm/FA.162.htm
• Texas DSHS, Health, Social, Education, and Genetic History Records — https://www.dshs.texas.gov/vital-statistics/adoption-information/health-social-education-genetic
• Official HSEGH Form — https://www.dshs.texas.gov/sites/default/files/vs/doc/Texas-HSEGH-Form.pdf
• Official HSEGH Addendum — https://www.dshs.texas.gov/sites/default/files/vs/doc/Texas-HSEGH-Addendum.doc
• Official HSEGH Information Cover Sheet — https://www.dshs.texas.gov/sites/default/files/vs/doc/Texas-HSEGH-Coversheet.pdf