Adoption Consent Form - Utah

UTAH PARENTAL CONSENT TO ADOPTION

1. ADOPTION PROCEEDING AND CHILD

Court: [______________] Judicial District Court / authorized Juvenile Court
County: [______________]
Case number (if filed): [______________]
Child: [FULL LEGAL NAME]
Date and place of birth: [__/__/____], [CITY, STATE]

Venue ordinarily lies in the judicial district where the prospective adoptive parent resides. If no prospective adoptive parent resides in Utah, use one of the locations permitted by Utah Code § 81-13-102(1)(b). A juvenile-court filing must fit § 81-13-102(1)(c) and the cited jurisdictional provisions.

2. CONSENTING PERSON

Full legal name: [________________________________]
Address: [________________________________]
Relationship or legal status (check and attach proof where applicable):

☐ Birth mother (§ 81-13-212(1)(c))
☐ Parent recognized by operation of law, subject to § 81-13-212(1)(b)(i)(A)-(C), or by a previous adoption (§ 81-13-212(1)(b))
☐ Parent adjudicated before the birth mother's consent or relinquishment (§ 81-13-212(1)(d))
☐ Declarant parent whose voluntary declaration was timely filed (§ 81-13-212(1)(e))
☐ Unmarried biological father whose consent is required under § 81-13-213 (§ 81-13-212(1)(f))
☐ Person or agency to whom the child was relinquished and that is placing the child (§ 81-13-212(1)(g))
☐ Other status, reviewed by counsel: [________________________________]

If the signer’s parental rights have already been terminated, § 81-13-212(2) provides that the signer’s consent is not required. This form should not be used as a substitute for a required termination proceeding.

3. CONSENT

I, [CONSENTING PERSON], freely and voluntarily consent to the adoption of [CHILD] by [PROSPECTIVE ADOPTIVE PARENT(S), IF DISCLOSED].

I understand that a final decree of adoption affects a pre-existing parent’s rights and duties as stated in Utah Code § 81-13-220. If, when the decree is entered, I am lawfully married to the person adopting the child, my rights and duties are preserved under § 81-13-220(2). Otherwise, the release of rights and duties occurs at the statutory time described in § 81-13-220(1), subject to any earlier termination order; § 81-13-220(5) does not terminate a support obligation incurred before adoption.

4. TIMING AND CAPACITY TO SIGN

1. Birth mother. I am the birth mother, and I sign at least 24 hours after the child’s birth (§ 81-13-212(4)(b)). Child’s birth date/time: [______________]. Signature date/time: [______________].
2. Other required consenter. If I am not the birth mother, § 81-13-212(4)(a) permits execution at any time, including before birth, subject to all other legal requirements.
3. Medication. If I am a birth parent, I am not signing while under anesthesia or medication that impairs my ability to think clearly (§ 81-13-212(6)(d)).
4. Minor birth parent. If I am younger than 18, I understand that § 81-13-212(5) gives my consent the same force and effect as an adult birth parent’s consent and that reaching 18 or becoming emancipated is not itself a basis to revoke.

5. REQUIRED MENTAL-HEALTH THERAPY NOTICE AND STATEMENT

Before I signed, I was informed of the mental-health therapy right described in Utah Code § 81-13-211. That section allows an eligible parent to select a professional licensed under Utah Code Title 58, Chapter 60 and describes up to three sessions of at least 50 minutes completed before relinquishment and up to three following relinquishment. The child-placing agency or prospective adoptive parents pay as § 81-13-211 provides, subject to an aggregate cap of $800 unless the affected parent and payer sign an agreement for more.

I acknowledge that I was advised of this statutory right before consenting, as required for the pre-decree statement under § 81-13-211(6).

☐ I elect to participate in therapy described by § 81-13-211.
☐ I waive the therapy right under § 81-13-211(3)(a).
☐ Counsel determined that I am not a “parent” entitled to the right under § 81-13-211(1) because: [________________________________].

6. BIRTH-PARENT REVOCATION NOTICE

Complete this section only if the signer is a birth parent.

1. Under Utah Code § 81-13-212(6)(a), a birth parent may revoke consent for any reason within 72 hours after consent.
2. A birth parent may waive that 72-hour period in writing (§ 81-13-212(6)(b)). Any waiver should be set out in a separate, clearly labeled writing reviewed by independent counsel. ☐ No waiver is attached. ☐ A separate written waiver is attached.
3. Before entry of the final decree, a birth parent may revoke if a court determines that the consent was given under duress, fraud, or undue influence by the child-placing agency (§ 81-13-212(6)(c)).
4. The rules in § 81-13-212(6)(a)-(d) do not apply to a voluntary relinquishment executed in juvenile court under § 80-4-307 (§ 81-13-212(6)(e)).

This form does not state that a non-birth-parent consenter has the same 72-hour right. Counsel must determine any rights of a signer who is not a birth parent.

7. FEES AND EXPENSES DISCLOSURE

I have disclosed to counsel and the prospective adoptive parent or agency all payments, promised payments, gifts, property, and support known to me in connection with this adoption so that the responsible person can determine what must be reported on the current Judicial Council affidavit.

Utah Code § 81-13-217 generally requires the prospective adoptive parent or placing person/agency to file a pre-decree fees-and-expenses affidavit. Section 81-13-217(6) makes that section inapplicable when the prospective adoptive parent is the legal spouse of a pre-existing parent.

8. ACKNOWLEDGMENTS

I acknowledge that:

☐ I have read this Consent or had it read to me.
☐ I understand this Consent and have had the opportunity to consult independent counsel.
☐ I sign freely and voluntarily.
☐ I have not relied on a promise that is not written here or in a separately identified, lawful agreement.
☐ I will receive a copy of this Consent as required by § 81-13-214(5).

9. SIGNATURE OF CONSENTING PERSON

________________________________________
Signature of Consenting Person

Printed name: [________________________________]
Date: [__/__/____]
Exact time: [____:____ ☐ a.m. ☐ p.m.]

10. REQUIRED EXECUTION FORMALITIES

A. Birth mother

A birth mother must sign before one of the persons listed in § 81-13-214(1):

☐ Judge of a court with adoption jurisdiction
☐ Person appointed by that judge
☐ Person authorized by a child-placing agency, only when the consent grants legal custody to a child-placing or extra-jurisdictional child-placing agency

A notary alone is not sufficient for a birth mother’s Utah consent. If a judge-appointed or agency-authorized person takes the signature under § 81-13-214(1)(b) or (c), the signature must also be notarized or witnessed by two people outside the birth mother’s immediate family (§ 81-13-214(6)). Out-of-state execution is governed by § 81-13-214(2).

B. Other parent described in § 81-13-211(1)

A person described in § 81-13-211(1) who is not the birth mother or child adoptee may sign before a notary or a person authorized under § 81-13-214(1) or (2) (§ 81-13-214(3)). Counsel must select the proper execution method for any other signer.

11. CERTIFICATION OR NOTARY ACKNOWLEDGMENT

A. Certification by person authorized under § 81-13-214(1) or (2)

I certify that I am authorized under Utah Code § 81-13-214(1) or (2) to take this Consent and, to the best of my information and belief, the signer has read and understands the Consent and signed it freely and voluntarily (§ 81-13-214(4)).

________________________________________
Signature of Authorized Person

Printed name/title: [________________________________]
Authority under § 81-13-214: [________________________________]
Date/time: [________________________________]

B. Additional notarization or two-witness block when § 81-13-214(6) applies

Notary acknowledgment: [________________________________]

OR

________________________________________
Witness 1 — not immediate family

________________________________________
Witness 2 — not immediate family

C. Notary acknowledgment for a signer permitted to use § 81-13-214(3)

State of [______________]
County of [______________]

The foregoing instrument was acknowledged before me on [__/__/____] by [CONSENTING PERSON].

________________________________________
Notary Public

My commission expires: [______________]

CURRENT OFFICIAL SOURCES VERIFIED JULY 23, 2026

• Utah Code § 81-13-102: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S102_2025090120250507.pdf
• Utah Code § 81-13-211: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S211_2026050620260506.pdf
• Utah Code § 81-13-212: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S212_2026050620260506.pdf
• Utah Code § 81-13-214: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S214_2025090120250507.pdf
• Utah Code § 81-13-217: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S217_2026050620260506.pdf
• Utah Code § 81-13-220: https://le.utah.gov/xcode/Title81/Chapter13/C81-13-S220_2025090120250507.pdf
• Utah Code § 80-4-307: https://le.utah.gov/xcode/Title80/Chapter4/C80-4-S307_2025090120250507.pdf