CONSENT TO TERMINATION OF PARENTAL RIGHTS AND ADOPTION

(State of Wisconsin – Wis. Stat. ch. 48)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Withdrawal of Consent & Revocation Parameters
7. Dispute Resolution
8. General Provisions
9. Acknowledgments & Certifications
10. Execution Block

1. DOCUMENT HEADER

1.1 Title. Consent to Termination of Parental Rights and Adoption (“Consent”).

1.2 Parties.
(a) “[FULL LEGAL NAME]” (“Consenting Parent”).
(b) “[FULL LEGAL NAME]” (“Child”), born on [DATE OF BIRTH] at [HOSPITAL/CITY], Wisconsin.
(c) “[FULL LEGAL NAME(S)]” (“Prospective Adoptive Parent(s)”) [optional].
(d) “[NAME OF LICENSED CHILD-PLACING AGENCY]” (“Agency”) [if applicable].

1.3 Effective Date. This Consent is effective on the date it is executed before the Court as required by Wis. Stat. § 48.41(2).

1.4 Governing Law & Venue. This Consent is governed by the laws of the State of Wisconsin. Exclusive venue lies in the [COUNTY] Circuit Court, Family Division (the “Court”).

2. DEFINITIONS

For purposes of this Consent:

“Agency” means the licensed Wisconsin child-placing agency identified above or any successor entity approved by the Court.

“Child” has the meaning set forth in Section 1.2(b).

“Court” has the meaning set forth in Section 1.4.

“Counselor” means the individual meeting Wis. Stat. § 48.24 credentials who provides the Counseling Sessions referenced in Section 3.4.

“Consenting Parent” has the meaning set forth in Section 1.2(a).

“Prospective Adoptive Parent(s)” has the meaning set forth in Section 1.2(c).

3. OPERATIVE PROVISIONS

3.1 Voluntary Consent. Consenting Parent hereby voluntarily, knowingly, and irrevocably (subject to Section 6) consents to:
(a) the termination of all parental rights to the Child; and
(b) the placement of the Child for adoption by the Agency or directly with the Prospective Adoptive Parent(s).

3.2 Timing Requirement. Consenting Parent affirms that this Consent is executed not earlier than seventy-two (72) hours after the Child’s birth in compliance with Wis. Stat. § 48.41(2)(a). The exact age of the Child at execution is ______ hours.

3.3 Court Appearance. Consenting Parent acknowledges that:
(a) this Consent must be reaffirmed personally before the Court; and
(b) the Court will determine whether the Consent is informed and voluntary as required by Wis. Stat. § 48.41(2)(b).

3.4 Counseling Sessions.
(a) Consenting Parent has been offered at least three (3) counseling sessions by a qualified Counselor, at no cost, in accordance with Wisconsin Department of Children & Families standards.
(b) Session dates: [MM/DD/YYYY], [MM/DD/YYYY], [MM/DD/YYYY].
(c) The attached Counselor Certificate (Section 9.2) confirms completion or proper waiver of these sessions.

3.5 Consideration. No monetary consideration, material promise, or inducement has been offered or accepted by the Consenting Parent other than permissible adoption-related expenses authorized by Wis. Stat. § 48.913.

4. REPRESENTATIONS & WARRANTIES

Consenting Parent represents and warrants to the Court and the Agency that:

a. Parentage & Authority. Consenting Parent is the Child’s legal [mother/father] and has full legal capacity to execute this Consent.
b. Absence of Coercion. No fraud, duress, or undue influence has been exerted.
c. Exclusive Rights. No other person holds custodial or parental rights to the Child, except as disclosed in Schedule 1 (Other Potential Parents) attached hereto.
d. Substance Capacity. Consenting Parent is not under the influence of any impairing substance.
e. Independent Advice. Consenting Parent has been advised of the right to consult independent counsel and either: (i) has had adequate opportunity to do so, or (ii) knowingly waives that right.

5. COVENANTS & RESTRICTIONS

a. Future Cooperation. Consenting Parent shall execute any further documents reasonably required to effectuate the adoption.
b. Contact Provisions. Any future contact with the Child shall occur only as permitted by a written Open Adoption Agreement approved under Wis. Stat. § 48.91(3) or by subsequent court order.
c. Confidentiality. Consenting Parent shall maintain confidentiality of identifying information concerning Prospective Adoptive Parent(s) unless disclosure is authorized by law or court order.

6. WITHDRAWAL OF CONSENT & REVOCATION PARAMETERS

6.1 Permissible Withdrawal Before TPR Order.
Consenting Parent may file a written petition with the Court to withdraw this Consent at any time before the Court enters the Order Terminating Parental Rights (“TPR Order”).

6.2 Effect of TPR Order.
Upon entry of the TPR Order, this Consent becomes final and irrevocable, subject only to:
a. appeal on the grounds of fraud or duress filed within thirty (30) days of notice of entry under Wis. Stat. § 808.04; and
b. any statutory right to seek relief from judgment under Wis. Stat. § 806.07.

6.3 Procedure.
Withdrawal petitions must comply with Wis. Stat. § 48.46 and be served upon all parties of record.

7. DISPUTE RESOLUTION

Because matters relating to adoption are within the exclusive jurisdiction of state courts:

a. Governing Law: State of Wisconsin.
b. Forum Selection: [COUNTY] Circuit Court, Family Division.
c. Arbitration: Not available.
d. Jury Waiver: All issues are to be decided by the Court sitting without a jury, consistent with “no_jury_family_court.”
e. Injunctive Relief: The Court retains authority to enter any orders necessary for permanent placement and the best interests of the Child.

8. GENERAL PROVISIONS

8.1 Entire Agreement. This Consent, including all attachments, constitutes the entire agreement regarding the matters herein and supersedes any prior statements.

8.2 Amendments. May be amended only in a writing executed by the Consenting Parent and approved by the Court before the TPR Order.

8.3 Severability. Any unenforceable provision shall be severed, and the remainder enforced to the fullest extent permitted by law.

8.4 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each deemed an original. Signatures transmitted electronically shall have the same force as originals pursuant to Wis. Stat. § 137.15.

9. ACKNOWLEDGMENTS & CERTIFICATIONS

9.1 Statement of Parental Rights (Wis. Stat. § 48.41(2)(e))

I, the Consenting Parent, acknowledge that the following has been read aloud to me by the Court (or that I have personally read and understood it):

1. I understand that signing this document may permanently end my parental rights to the Child.
2. I understand that I may withdraw my consent at any time before the Court enters a TPR Order, but not after, except as permitted by law.
3. I understand that the Child may be adopted by the Prospective Adoptive Parent(s) or another suitable adoptive parent.
4. I understand that I have the right to independent legal counsel and counseling services at no cost.
5. I have received a copy of this signed Consent.

Initials of Consenting Parent: _________

9.2 Counselor Certificate

I, [COUNSELOR NAME], certify that I am qualified under Wisconsin law and that:
☐ The Consenting Parent attended the counseling sessions listed in Section 3.4(b); OR
☐ The Consenting Parent knowingly and voluntarily declined such sessions.

Signature of Counselor: _________________________ Date: _____________

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the undersigned executes this Consent as of the Effective Date.

[Notary Block]
State of Wisconsin )
County of ☐ )

Subscribed and sworn to before me on ____________, 20___, by _____________________________, who is personally known to me or who presented satisfactory evidence of identity.

________________________________________
Notary Public, State of Wisconsin
My Commission Expires: ________________

COURT APPROVAL

Presented to the Court this ____ day of ____________, 20__.

The Court finds that the Consenting Parent’s consent is informed, voluntary, and in compliance with Wis. Stat. § 48.41. The Court hereby accepts the Consent.

________________________________________
Circuit Court Judge

Case No.: _________________