PRIVATE ADOPTION PLACEMENT AGREEMENT

AGREEMENT INFORMATION

PARTIES TO THIS AGREEMENT

Birth Parent(s)

Birth Mother:

Birth Father (if known and participating):

Paternity Status:

☐ Birth father is named on birth certificate

☐ Birth father has signed acknowledgment of paternity

☐ Paternity established by court order

☐ Birth father's identity is unknown

☐ Birth father's whereabouts are unknown

☐ Other: _____________

Prospective Adoptive Parent(s)

Adoptive Parent 1:

Adoptive Parent 2 (if applicable):

SECTION I: CHILD INFORMATION

1.1 Child to be Adopted

☐ Child is already born

☐ Child is expected to be born on approximately [DUE DATE]

If child is born:

1.2 Prenatal Information (if child not yet born)

SECTION II: ADOPTION SERVICE PROVIDER

2.1 Licensed Adoption Service Provider (if required by state)

2.2 Services to be Provided

☐ Birth parent counseling

☐ Home study services

☐ Post-placement supervision

☐ Court report preparation

☐ ICPC processing (if interstate)

☐ Other: _____________

SECTION III: REPRESENTATIONS AND DISCLOSURES

3.1 Birth Mother Representations

Birth Mother represents and warrants:

☐ I am the biological mother of the child

☐ I am at least [18] years of age OR I have obtained required parental consent/court approval for this adoption

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

☐ I have received no consideration for this adoption other than lawful expenses

☐ I am entering this agreement voluntarily and without coercion

☐ I understand I have the right to independent legal counsel

☐ I have been advised of my right to parent my child

☐ I have been advised of available public assistance programs

☐ I have disclosed all known information about the birth father

☐ I have disclosed all known medical and genetic history

☐ I am not aware of any other person claiming parental rights

3.2 Birth Father Representations (if participating)

Birth Father represents and warrants:

☐ I am the biological father of the child OR I have reason to believe I am the biological father

☐ I am at least [18] years of age OR I have obtained required consents

☐ I am entering this agreement voluntarily and without coercion

☐ I understand I have the right to independent legal counsel

☐ I have been advised of my rights as a father

☐ I have disclosed all known medical and genetic history

3.3 Adoptive Parent Representations

Adoptive Parent(s) represent and warrant:

☐ We have met all state requirements for adoptive parents

☐ We have completed or will complete a home study as required

☐ We have no disqualifying criminal convictions

☐ We have not made any unlawful payments to birth parent(s)

☐ We understand we cannot be assured of a successful adoption until finalization

☐ We have independent legal counsel

☐ We will provide a safe, loving, and nurturing home for the child

☐ We are financially able to support the child

SECTION IV: MEDICAL AND SOCIAL HISTORY

4.1 Birth Parent Agreement to Disclose

Birth Parent(s) agree to provide:

☐ Complete medical history of birth mother

☐ Complete medical history of birth father (if known)

☐ Family medical history (both sides)

☐ Social and educational history

☐ Genetic information (if known)

☐ Information about siblings (if any)

☐ Prenatal care records

☐ Hospital/birth records

☐ Any known special needs or health conditions

4.2 Ongoing Medical Information

☐ Birth Parent(s) agree to provide updated medical information if significant conditions are discovered in the future

☐ Adoptive Parents agree to maintain confidential method for birth parents to share updated medical information

SECTION V: CONSENT AND RELINQUISHMENT

5.1 Timing of Consent

IMPORTANT: Consent timing requirements vary significantly by state.

☐ Birth mother consent cannot be signed until [HOURS/DAYS] after birth

☐ Birth father consent can be signed: ☐ Before birth ☐ Only after birth

☐ Required waiting period: [NUMBER] hours/days after birth

5.2 Revocation Period

IMPORTANT: Revocation periods vary significantly by state.

☐ Birth mother revocation period: [NUMBER] days

☐ Birth father revocation period: [NUMBER] days

☐ Revocation must be in writing: ☐ Yes ☐ No

☐ After revocation period, consent is: ☐ Irrevocable ☐ Revocable only for cause

5.3 Effect of Consent

Upon signing consent and expiration of revocation period:

☐ Birth parent relinquishes all parental rights

☐ Birth parent consents to adoption by Adoptive Parents

☐ Birth parent waives right to notice of adoption proceedings

☐ Birth parent's rights and responsibilities are terminated

SECTION VI: PLACEMENT

6.1 Placement Timing

☐ Child will be placed directly from hospital

☐ Child will be placed [NUMBER] days after birth

☐ Child is already in Adoptive Parents' care (Date: _____________)

☐ Other: _____________

6.2 Placement Process

☐ Birth Parent(s) will personally place child with Adoptive Parents

☐ Placement will occur through Adoption Service Provider

☐ Placement will occur through attorney intermediary (if permitted)

6.3 Interstate Compact on Placement of Children (ICPC)

☐ This is an intrastate adoption (same state) - ICPC does not apply

☐ This is an interstate adoption - ICPC DOES APPLY

If ICPC applies:

☐ Sending state: [STATE]

☐ Receiving state: [STATE]

☐ ICPC approval must be obtained BEFORE child crosses state lines

☐ ICPC Coordinator (Sending State): _____________

☐ ICPC Coordinator (Receiving State): _____________

SECTION VII: EXPENSES AND FINANCIAL ARRANGEMENTS

7.1 Permitted Birth Parent Expenses

IMPORTANT: Permitted expenses and amounts are strictly regulated by state law. This section must be reviewed by legal counsel.

The following expenses may be paid on behalf of Birth Parent (check only those permitted by applicable state law):

☐ Medical expenses related to pregnancy and birth

☐ Hospital expenses

☐ Attorney fees for birth parent

☐ Counseling expenses

☐ Reasonable living expenses: ☐ Rent ☐ Utilities ☐ Food ☐ Transportation

☐ Maternity clothing

☐ Other permitted expenses: _____________

7.2 Expense Limits

7.3 Payment Method

☐ All payments made directly to service providers (not to birth parent)

☐ Payments documented and subject to court approval

☐ Itemized accounting will be provided to court

7.4 Non-Refundable Nature of Expenses

☐ All parties understand that expenses paid to or on behalf of Birth Parent are NOT refundable if the adoption does not proceed

☐ Adoptive Parents have been advised of this risk

SECTION VIII: HOME STUDY REQUIREMENTS

8.1 Home Study Status

☐ Home study completed (Date: _____________; Expires: _____________)

☐ Home study in progress

☐ Home study not yet started

Home Study Provider:

8.2 Home Study Requirements

☐ Criminal background checks (state and federal)

☐ Child abuse registry clearances

☐ Home safety inspection

☐ Personal interviews

☐ Medical reports

☐ Financial documentation

☐ References

☐ Pre-adoption training (if required)

SECTION IX: POST-ADOPTION CONTACT

9.1 Type of Adoption

☐ Closed adoption - no post-adoption contact

☐ Semi-open adoption - limited contact through intermediary

☐ Open adoption - direct contact provisions (see attached Post-Adoption Contact Agreement)

9.2 Contact During Placement Period

☐ Birth Parent(s) may contact child/Adoptive Parents during placement period

☐ Contact method: _____________

☐ Contact frequency: _____________

SECTION X: RISK ACKNOWLEDGMENTS

10.1 Adoptive Parents Acknowledge

☐ Birth Parent(s) may change their mind and reclaim the child during the revocation period

☐ No guarantee of a successful adoption exists until finalization

☐ Expenses paid are non-refundable if adoption does not proceed

☐ The child's health and development cannot be guaranteed

☐ Undisclosed birth fathers may assert rights

☐ The adoption process may take [ESTIMATED TIME]

10.2 Birth Parents Acknowledge

☐ This is a permanent, irrevocable decision (after revocation period)

☐ Termination of parental rights means no legal relationship with child

☐ No guaranteed right to future contact unless agreed and enforceable

☐ Decision was made voluntarily and without coercion

☐ Counseling services are available

SECTION XI: LEGAL REPRESENTATION

11.1 Independent Counsel

☐ Birth Mother has independent legal counsel: [ATTORNEY NAME]

☐ Birth Mother has been advised of right to counsel and declined

☐ Birth Father has independent legal counsel: [ATTORNEY NAME]

☐ Birth Father has been advised of right to counsel and declined

☐ Adoptive Parents have legal counsel: [ATTORNEY NAME]

11.2 No Conflict

☐ All parties acknowledge they have been advised to obtain independent legal counsel

☐ No attorney is representing both birth parent(s) and adoptive parent(s)

SECTION XII: TERMINATION OF AGREEMENT

12.1 Termination by Birth Parent(s)

Birth Parent(s) may terminate this Agreement:

☐ At any time before signing consent

☐ During the revocation period after signing consent

☐ Effect of termination: [DESCRIBE]

12.2 Termination by Adoptive Parents

Adoptive Parents may terminate this Agreement:

☐ At any time before placement, with notice to birth parent(s)

☐ Effect of termination: [DESCRIBE]

12.3 Effect on Expenses

Upon termination:

☐ Expenses already paid are non-refundable

☐ Future expense obligations cease

STATE-SPECIFIC NOTES

California

• Independent adoption governed by California Family Code Sections 8800-8823
• Adoption Placement Agreement cannot be signed until 10 days after first meeting with ASP
• Birth parent has 30 days after signing to revoke consent
• Adoptive parents must be at least 10 years older than child
• Child 12+ must consent
• Court approval required for birth parent expenses exceeding limits

Texas

• Independent adoption governed by Texas Family Code Chapter 162
• Consent can be signed any time after 48 hours after birth
• Consent becomes irrevocable after 11th day OR upon court rendering order terminating rights
• Licensed child-placing agency or DFPS must conduct social study
• Birth parent expenses strictly regulated

Florida

• Private adoption governed by Chapter 63, Florida Statutes
• Consent cannot be signed until 48 hours after birth (or hospital discharge, whichever earlier)
• 3 business day revocation period for children 6+ months old
• Intermediary (attorney or agency) involvement required
• Detailed accounting of expenses required for court

New York

• Private-placement adoption governed by NY Domestic Relations Law Article 7
• Extra-judicial consent valid if properly executed
• Court must approve all fees and expenses
• Criminal background and child abuse clearances required
• Child 14+ must consent
• Not all attorneys can serve as intermediaries

SECTION XIII: SIGNATURES

BIRTH MOTHER:

I have read this Agreement, understand its terms, and agree to be bound by it. I have had the opportunity to consult with legal counsel. I am signing voluntarily and not under duress.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

BIRTH FATHER (if applicable):

I have read this Agreement, understand its terms, and agree to be bound by it. I have had the opportunity to consult with legal counsel. I am signing voluntarily and not under duress.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

ADOPTIVE PARENT 1:

I have read this Agreement, understand its terms, and agree to be bound by it.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

ADOPTIVE PARENT 2 (if applicable):

I have read this Agreement, understand its terms, and agree to be bound by it.

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

NOTARY ACKNOWLEDGMENT

State of [STATE]
County of [COUNTY]

On [DATE], before me, a Notary Public, personally appeared the above-named individuals, proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged that they executed the same.

WITNESS my hand and official seal.

Notary Signature: _________________________________

Print Name: _________________________________

Commission Expires: _________________________________

[NOTARY SEAL]

WITNESS ATTESTATION (if required)

We, the undersigned witnesses, attest that the above parties signed this Agreement in our presence, appeared to be of sound mind, and signed voluntarily.

Witness 1:

Signature: _________________________________

Print Name: _________________________________

Address: _________________________________

Date: _________________________________

Witness 2:

Signature: _________________________________

Print Name: _________________________________

Address: _________________________________

Date: _________________________________

ATTACHMENTS

☐ Attachment A: Home Study Report

☐ Attachment B: Medical/Social History Form

☐ Attachment C: Expense Itemization

☐ Attachment D: Post-Adoption Contact Agreement (if applicable)

☐ Attachment E: ICPC Forms (if interstate)

DOCUMENT CONTROL

This Agreement is provided for informational purposes only. Private/independent adoption laws and permissible expenses vary significantly by state. Some states prohibit or restrict private adoption. Consult with a qualified adoption attorney licensed in your jurisdiction before proceeding.