Adoption Consent Form - Washington

CONSENT OF PARENT TO ADOPTION

Before you use this: Confirm the required consents and the receiving court's filing instructions. For an Indian child, use the additional timing, court-recording, and withdrawal provisions below; obtain review of applicable federal and tribal requirements before signing.

Superior Court of Washington, County of [COUNTY]

Adoption of [CHILD'S FULL LEGAL NAME], born [DATE AND TIME OF BIRTH]

Case No. [CASE NUMBER, IF ASSIGNED]

Parent and proposed adoption

I, [CONSENTING PARENT'S FULL LEGAL NAME], of [MAILING ADDRESS], am the child's [PARENT / ALLEGED FATHER]. I consent to the adoption of the child by [PROSPECTIVE ADOPTIVE PARENT OR PARENTS] and request that the court approve this consent. I give this consent voluntarily. It is subject to court approval and has no force or effect until the court approves it.

The birth parent is: ☐ of Native American or Alaska Native ancestry; ☐ not of Native American or Alaska Native ancestry. Birth parent's name: [NAME]. If ancestry or the child's status as an Indian child is uncertain, disclose that uncertainty to the court before presenting this consent.

Clerk of the court where this consent will be presented:

Court: [COURT NAME]

Mailing or delivery address: [FULL CLERK ADDRESS]

Presentation and revocation

This consent will not be presented to the court for approval until 48 hours after I sign it or 48 hours after the child's birth, whichever is later. The child was born at [TIME] on [DATE]. I sign at [TIME] on [DATE]. The earliest presentation time is [TIME] on [DATE].

Except for the Indian-child provisions below, I may revoke this consent at any time before the court approves it by delivering or mailing written revocation to the clerk identified above. Written revocation may also be delivered or mailed to that clerk after approval only if it is delivered or mailed within 48 hours after a prior revocation notice given within 48 hours after the child's birth. That prior notice must be given to the agency or person who sought my consent and may be oral or written.

Except for that birth-related notice procedure and the Indian-child provisions below, after court approval this consent cannot be revoked unless, within one year after approval, revocation is sought for fraud or duress practiced by the person, department, or agency requesting it, or for my lack of mental competency when I gave it. A written consent cannot be revoked more than one year after court approval.

Additional provisions if the child is an Indian child

If this is a consent to adoption of an Indian child, no consent is valid unless it is executed in writing more than ten days after the child's birth and recorded before a court of competent jurisdiction as required by RCW 26.33.160(4)(h). I may withdraw consent for any reason before entry of the final adoption decree. I may withdraw it for fraud or duress within two years after entry of that decree. Before the final decree, I may deliver or mail revocation to the court clerk, or make it orally to the court, which must certify it; revocation is effective if the clerk receives it before entry of the decree or I make it orally to the court before entry of the decree. Upon withdrawal, the court returns the child to the parent except in the protective-custody, shelter-care, or foster-care circumstances stated in RCW 26.33.160(4)(h).

☐ These Indian-child provisions apply. ☐ The child's Indian-child status requires determination before this consent is presented.

Required statement read before signing

I have read the following statement before signing:

I understand that my decision to relinquish the child is an extremely important one, that the legal effect of this relinquishment will be to take from me all legal rights and obligations with respect to the child, and that an order permanently terminating all of my parental rights to the child will be entered. I also understand that there are social services and counseling services available in the community, and that there may be financial assistance available through state and local governmental agencies.

Signature under penalty of perjury

I declare under penalty of perjury under the laws of the State of Washington that the statements I made in this consent are true and correct.

Signed at [CITY, STATE] on [DATE] at [TIME].

Consenting parent's signature: [SIGNATURE]

Printed name: [FULL LEGAL NAME]

Parent-selected adult witness

I, [WITNESS NAME], am at least 18 years old and was selected by the consenting parent to witness this consent. I witnessed that parent's signature.

Witness signature: [SIGNATURE]

Witness full name: [NAME]

Witness address: [FULL ADDRESS]

Witness relationship to consenting parent: [RELATIONSHIP]

Date and time witnessed: [DATE AND TIME]

Source

• RCW 26.33.160, Consent to adoption