CONSENT TO ADOPTION

DOCUMENT INFORMATION

PART A: CONSENTING PARENT INFORMATION

A.1 Identifying Information

A.2 Relationship to Child

☐ Biological Mother

☐ Biological Father

☐ Legal Father (by marriage or court order)

☐ Presumed Father (by acknowledgment of paternity)

☐ Alleged Father

☐ Legal Parent (by adoption or other order)

☐ Legal Guardian

A.3 Legal Representation

☐ I have been represented by an attorney in connection with this consent

Attorney Name: _________________________________

Attorney Address: _________________________________

Attorney Phone: _________________________________

☐ I have been advised of my right to be represented by an attorney and have chosen not to be represented

☐ I have been offered attorney representation at no cost and have declined

PART B: CHILD INFORMATION

B.1 Child Identifying Information

B.2 Multiple Children (if applicable)

☐ This consent applies to one child only (named above)

☐ This consent applies to multiple children:

PART C: ADOPTIVE PARENT(S) INFORMATION

C.1 Named Adoptive Parent(s)

☐ I consent to adoption by the following specific person(s):

Adoptive Parent 1:

Adoptive Parent 2 (if applicable):

C.2 Agency Placement

☐ I consent to adoption by person(s) selected by the following licensed adoption agency:

PART D: CONSENT STATEMENTS

D.1 Voluntary Consent

I, [CONSENTING PARENT NAME], hereby state:

☐ I am the ☐ biological mother ☐ biological father ☐ legal parent of the child named above

☐ I voluntarily and of my own free will consent to the adoption of my child

☐ I have not been coerced, threatened, or unduly influenced to sign this consent

☐ I have not been promised anything other than lawful adoption-related expenses

☐ I am not under the influence of any substance that impairs my judgment

☐ I am signing this consent freely and voluntarily

D.2 Understanding of Rights

I understand and acknowledge:

☐ I have the right to parent my child

☐ I have the right to refuse to consent to this adoption

☐ I have the right to consult with an attorney before signing this consent

☐ I have had sufficient time to consider this decision

☐ I may be entitled to public assistance if I choose to parent

☐ Counseling services are available to me

D.3 Understanding of Consequences

I understand that by signing this consent:

☐ I am giving up all rights to my child, including:
- The right to custody of my child
- The right to visit my child
- The right to make decisions about my child's upbringing
- The right to be notified about my child's welfare
- The right to inherit from my child (and vice versa)

☐ This consent, once final, is permanent and cannot be undone

☐ My child will become the legal child of the adoptive parent(s)

☐ A new birth certificate will be issued naming the adoptive parent(s)

☐ I will have no further legal rights or responsibilities toward my child

D.4 Timing Acknowledgment

☐ This consent is being signed at least [NUMBER] hours after the birth of my child (per [STATE] law)

☐ I was first presented with this consent form on [DATE]

☐ I have had [NUMBER] days to review this consent before signing

PART E: REVOCATION RIGHTS

E.1 Revocation Period

CRITICAL: REVOCATION PERIODS VARY BY STATE

I understand that under the laws of [STATE]:

☐ I have [NUMBER] days after signing this consent to revoke (take back) my consent

☐ After the revocation period expires, my consent becomes irrevocable

☐ My consent is irrevocable upon signing (if applicable in this state)

☐ My consent may only be revoked by: [DESCRIBE METHOD REQUIRED]

☐ To revoke my consent, I must: [DESCRIBE REQUIRED PROCEDURE]

E.2 Method of Revocation

To revoke this consent within the revocation period, I must:

☐ Provide written notice to: [NAME/AGENCY/COURT]

☐ Address for revocation notice: [ADDRESS]

☐ Notice must be delivered by: ☐ Personal Delivery ☐ Certified Mail ☐ Other: _____________

☐ Verbal revocation is: ☐ Sufficient ☐ Not sufficient

E.3 Effect of Revocation

If I revoke my consent within the allowed period:

☐ The child shall be returned to my custody

☐ The adoption proceedings shall cease

☐ Any expenses paid on my behalf are NOT required to be repaid (in most states)

PART F: WAIVER OF RIGHTS

F.1 Waiver of Notice

☐ I waive my right to receive notice of any further proceedings in this adoption matter

☐ I waive my right to appear at any hearing related to this adoption

☐ I consent to the adoption being finalized without further notice to me

F.2 Waiver of Other Rights

☐ I waive any right to contest this adoption after the revocation period expires

☐ I waive any right to custody, visitation, or contact with the child (unless specified in a separate enforceable agreement)

PART G: ADDITIONAL ACKNOWLEDGMENTS

G.1 Other Parent

☐ The other parent of this child is: [NAME]

☐ The identity of the other parent is unknown

☐ I understand the other parent's consent may also be required

☐ I have provided all information known to me about the other parent

G.2 Native American Heritage

Under the Indian Child Welfare Act (ICWA):

☐ To my knowledge, the child is NOT a member or eligible for membership in a federally recognized Indian tribe

☐ The child IS or MAY BE a member or eligible for membership in: [TRIBE NAME]

☐ I have disclosed all information known to me about potential Indian heritage

G.3 Post-Adoption Contact

☐ I understand this consent does not include any agreement for post-adoption contact

☐ A separate Post-Adoption Contact Agreement has been executed (attached)

☐ Any post-adoption contact is at the discretion of the adoptive parents (unless enforceable agreement exists)

G.4 Medical and Social History

☐ I have provided complete medical and social history information

☐ I agree to provide updated medical information if significant conditions are discovered

PART H: STATE-SPECIFIC REQUIREMENTS

California

• Consent cannot be signed until 10 days after first meeting with Adoption Service Provider
• 30-day revocation period from date of signing
• Consent must be signed before a notary or authorized official
• California Family Code Section 8814.5

Texas

• Consent can be signed 48 hours after birth
• Becomes irrevocable after 11th day or court order
• Must be witnessed by two credible adults
• Texas Family Code Section 161.103

Florida

• Mother cannot consent until 48 hours after birth or hospital discharge
• 3 business day revocation period (children 6+ months)
• Must be signed before two witnesses and notary
• Chapter 63, Florida Statutes, Sections 63.062-63.082

New York

• Extra-judicial consent must be acknowledged before notary
• Judicial consent before judge is also an option
• No statutory revocation period for private placements
• Child 14+ must also consent
• NY Domestic Relations Law Article 7

PART I: CERTIFICATION OF UNDERSTANDING

I, [CONSENTING PARENT NAME], certify that:

☐ I have read this entire document (or it has been read to me)

☐ I understand all of the statements in this document

☐ I have asked any questions I had and received satisfactory answers

☐ No one has forced or pressured me to sign this consent

☐ I am signing this consent of my own free will

☐ I understand this consent will result in the permanent termination of my parental rights

☐ I have been given a copy of this signed consent

PART J: SIGNATURES

Consenting Parent Signature

I, [CONSENTING PARENT NAME], execute this Consent to Adoption on the date indicated below.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

Time: _________________________________

Location of Signing: _________________________________

Witness Attestation

We, the undersigned witnesses, being first duly sworn, state:

☐ We are both adults and not parties to this adoption

☐ We personally witnessed the signing of this consent

☐ The consenting parent appeared to be of sound mind

☐ The consenting parent did not appear to be under duress or coercion

☐ The consenting parent did not appear to be under the influence of any substance

Witness 1:

Signature: _________________________________

Print Name: _________________________________

Address: _________________________________

Date: _________________________________

Witness 2:

Signature: _________________________________

Print Name: _________________________________

Address: _________________________________

Date: _________________________________

Notary Acknowledgment

State of [STATE]
County of [COUNTY]

On [DATE], before me, [NOTARY NAME], a Notary Public, personally appeared [CONSENTING PARENT NAME], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged that they executed the same.

The consenting parent:
☐ Appeared to be of sound mind and under no duress
☐ Acknowledged understanding the nature and consequences of this consent
☐ Was provided a copy of this document

WITNESS my hand and official seal.

Notary Signature: _________________________________

Print Name: _________________________________

My Commission Expires: _________________________________

Commission Number: _________________________________

[NOTARY SEAL]

Attorney Certification (if applicable)

I, [ATTORNEY NAME], attorney for the consenting parent, certify:

☐ I have advised my client of the legal effects of this consent

☐ I have advised my client of their right to revoke within the allowed period

☐ I have advised my client of alternatives to adoption

☐ My client has executed this consent knowingly and voluntarily

☐ I have no conflict of interest in this matter

Attorney Signature: _________________________________

Print Name: _________________________________

State Bar Number: _________________________________

Date: _________________________________

Agency Representative Certification (if agency adoption)

I, [REPRESENTATIVE NAME], authorized representative of [AGENCY NAME], certify:

☐ This consent was obtained in compliance with all state requirements

☐ The consenting parent received required counseling

☐ The consenting parent was advised of their rights

☐ The consenting parent was offered legal representation

☐ No improper inducements were offered

Signature: _________________________________

Print Name: _________________________________

Title: _________________________________

Date: _________________________________

PART K: REVOCATION NOTICE FORM

Detach and retain for your records

NOTICE OF REVOCATION OF CONSENT TO ADOPTION

TO: [NAME OF AGENCY/ATTORNEY/COURT]

ADDRESS: [ADDRESS]

I, [YOUR NAME], hereby revoke my Consent to Adoption signed on [DATE] concerning the child:

Child's Name: _________________________________

Child's Date of Birth: _________________________________

I revoke my consent effective immediately.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

Time: _________________________________

Method of Delivery: ☐ Personal Delivery ☐ Certified Mail ☐ Other: _____________

IMPORTANT INFORMATION

KEEP A COPY OF THIS DOCUMENT

REVOCATION DEADLINE: If you wish to revoke this consent, you must do so by: [DATE]

Contact for Revocation: [NAME/AGENCY]

Address: [ADDRESS]

Phone: [PHONE]

DOCUMENT CONTROL

This Consent to Adoption is provided for informational purposes only. Consent requirements, timing, and revocation periods vary significantly by state. This document has permanent legal consequences. Consult with a qualified attorney licensed in your jurisdiction before signing.