100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB5155

 

Introduced , by Rep. Sara Feigenholtz

 

SYNOPSIS AS INTRODUCED:
 
750 ILCS 50/10  from Ch. 40, par. 1512

    Amends the Adoption Act. Makes various changes to certain statutory adoption consent forms, including changes concerning: the inclusion of the names of persons granted consent to adopt; the provision of the email address, cell phone number, and land line phone number at which the person signing the consent can be provided with notice if the specified person does not adopt the child; procedural matters; and the effect of consent if the persons granted consent are granted a dissolution of marriage or dissolution of a civil union or one of the persons granted consent dies.


LRB100 16596 HEP 35707 b

 

 

A BILL FOR

 

HB5155LRB100 16596 HEP 35707 b

1    AN ACT concerning civil law.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Adoption Act is amended by changing Section
510 as follows:
 
6    (750 ILCS 50/10)  (from Ch. 40, par. 1512)
7    Sec. 10. Forms of consent and surrender; execution and
8acknowledgment thereof.
9    A. The form of consent required for the adoption of a born
10child shall be substantially as follows:
 
11
FINAL AND IRREVOCABLE CONSENT TO ADOPTION

 
12    I, ...., (relationship, e.g., mother, father, relative,
13guardian) of ...., a ..male or female (circle one) child,
14state:
15    That such child was born on .... at ....
16    That I reside at ...., County of .... and State of ....
17    That I am of the age of .... years.
18    That I hereby enter my appearance in this proceeding and
19waive service of summons on me.
20    That I hereby acknowledge that I have been provided with a
21copy of the Birth Parent Rights and Responsibilities-Private

 

 

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1Form before signing this Consent and that I have had time to
2read, or have had read to me, this Form. I understand that if I
3do not receive any of the rights as described in this Form, it
4shall not constitute a basis to revoke this Final and
5Irrevocable Consent.
6    That I do hereby consent and agree to the adoption of such
7child.
8    That I wish to and understand that by signing this consent
9I do irrevocably and permanently give up all custody and other
10parental rights I have to such child.
11    That I understand such child will be placed for adoption
12and that I cannot under any circumstances, after signing this
13document, change my mind and revoke or cancel this consent or
14obtain or recover custody or any other rights over such child.
15That I have read and understand the above and I am signing it
16as my free and voluntary act.
17    Dated (insert date).
18.........................
 
19    If under Section 8 the consent of more than one person is
20required, then each such person shall execute a separate
21consent.
22    A-1. (1) The form of the Final and Irrevocable Consent to
23Adoption by a Specified Person or Persons: Non-DCFS Case set
24forth in this subsection A-1 is to be used by legal parents
25only. This form is not to be used in cases in which there is a

 

 

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1pending petition under Section 2-13 of the Juvenile Court Act
2of 1987.
3    (2) The form of the Final and Irrevocable Consent to
4Adoption by a Specified Person or Persons in a non-DCFS case
5shall have the caption of the proceeding in which it is to be
6filed and shall be substantially as follows:
 
7
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
8
A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE

 
9    I, ...., (relationship, e.g., mother, father) of ...., a
10..male or female (circle one) child, state:
11    1. That such child was born on ...., at ....., in the
12City/Town of ... and State of ....
13    2. That I reside at ...., County of .... and State of ....,
14my email address (if I have one) is .... my cell phone number
15where I can receive text messages (if I have one) is .... and
16my land line phone number (if I have one) is ...., and any
17other contract information is ....
18    3. That I am of the age of .... years.
19    4. That I hereby enter my appearance in this proceeding and
20waive service of summons on me.
21    5. That I hereby acknowledge that I have been provided a
22copy of the Birth Parent Rights and Responsibilities-Private
23Form before signing this Consent and that I have had time to
24read, or have had read to me, this Form and that I understand

 

 

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1the Rights and Responsibilities described in this Form. I
2understand that if I do not receive any of my rights as
3described in said Form, it shall not constitute a basis to
4revoke this Final and Irrevocable Consent to Adoption by a
5Specified Person.
6    6. That I do hereby consent and agree to the adoption of
7such child by .... (specified person or persons) only. If only
8first names are used for the specified person or persons, I
9voluntarily sign this specified consent form without
10disclosure to me of the last name of the specified person or
11persons. However, I understand that if I wish to know the last
12name of the specified person or persons, I may request it
13before signing the form. If I do not receive the last name, I
14may choose not to sign the specified consent form.
15    7. That I wish to and understand that upon signing this
16consent I do irrevocably and permanently give up all custody
17and other parental rights I have to such child if such child is
18adopted by .... (specified person or persons). I hereby
19transfer all of my rights to the custody, care and control of
20such child to ............................. (specified person
21or persons).
22    8. That I understand such child will be adopted by
23....................... (specified person or persons) and that
24I cannot under any circumstances, after signing this document,
25change my mind and revoke or cancel this consent or obtain or
26recover custody or any other rights over such child if

 

 

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1............................ (specified person or persons)
2adopt(s) such child; PROVIDED that each specified person has
3filed or shall file, within 60 days from the date hereof, a
4petition for the adoption of such child.
5    9. That if the specified person or persons designated
6herein do not file a petition for adoption within the
7time-frame specified above, or, if said petition for adoption
8is filed within the time-frame specified above but the adoption
9petition is dismissed with prejudice or the adoption proceeding
10is otherwise concluded without an order declaring the child to
11be the adopted child of the specified person or persons, then I
12understand that I will be sent receive written notice of such
13circumstances at the mailing address, at the email address,
14through a text message to my cell phone number, and to any
15other contact information I have provided in paragraph 2 within
165 10 business days of this their occurrence. I understand that
17the notice will be directed to me using the contact information
18I have provided in this consent. I understand that I will have
1915 10 business days from the date that the written notice is
20sent to me to respond in the manner described in the notice,
21within which time I may request the Court to declare this
22consent voidable and return the child to me. I further
23understand that the Court will make the final decision of
24whether or not the child will be returned to me. If I do not
25make such request within 15 10 business days of the date of the
26notice was sent, then I expressly waive any other notice or

 

 

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1service of process in any legal proceeding regarding the child,
2including a legal proceeding for someone other than .....
3(specified person or persons) to adopt for the adoption of the
4child, and that I will have no parental rights as to the child.
5The person sending the notice shall file an affidavit of notice
6as proof of the date sent.
7    10. That I expressly acknowledge that nothing in this
8Consent impairs the validity and absolute finality of this
9Consent under any circumstance other than those described in
10paragraph 9 of this Consent.
11    11. That I understand that I have a remaining duty and
12obligation to keep .............. (insert name and address of
13the attorney for the specified person or persons) informed of
14my current address or other preferred contact information until
15this adoption has been finalized. My failure to do so may
16result in the termination of my parental rights and the child
17being placed for adoption in another home.
18    12. That I do expressly waive any other notice or service
19of process in any of the legal proceedings for the adoption of
20the child as long as the adoption proceeding by the specified
21person or persons is pending.
22    13. That I have read and understand the above and I am
23signing it as my free and voluntary act.
24    14. That I acknowledge that this consent is valid even if
25the specified person or persons separate or divorce or one of
26the specified persons dies prior to the entry of the final

 

 

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1judgment for adoption.
2    Dated (insert date).
3    .............................................
4    Signature of parent.
5    .............................................
6    Address of parent.
7    .............................................
8    Phone number(s) of parent.
9    .............................................
10    Personal email(s) of parent.
11    .............................................
 
12    (3) The form of the certificate of acknowledgement for a
13Final and Irrevocable Consent for Adoption by a Specified
14Person or Persons: Non-DCFS Case shall be substantially as
15follows:
 
16STATE OF ..............)
17                       ) SS.
18COUNTY OF .............)
19    I, .................... (Name of Judge or other person),
20..................... (official title, name, and address),
21certify that ............., personally known to me to be the
22same person whose name is subscribed to the foregoing Final and
23Irrevocable Consent for Adoption by a Specified Person or
24Persons; non-DCFS case, appeared before me this day in person

 

 

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1and acknowledged that (she)(he) signed and delivered the
2consent as (her)(his) free and voluntary act, for the specified
3purpose. I am further satisfied that, before signing this
4Consent, ........ has read, or has had read to him or her, the
5Birth Parent Rights and Responsibilities-Private Form.
 
6    A-2. Birth Parent Rights and Responsibilities-Private
7Form. The Birth Parent Rights and Responsibilities-Private
8Form must be read by, or have been read to, any person
9executing a Final and Irrevocable Consent to Adoption under
10subsection A, a Final and Irrevocable Consent to Adoption by a
11Specified Person or Persons: Non-DCFS Case under subsection
12A-1, or a Consent to Adoption of Unborn Child under subsection
13B prior to the execution of said Consent. The form of the Birth
14Parent Rights and Responsibilities-Private Form shall be
15substantially as follows:
 
16
Birth Parent Rights and Responsibilities-Private Form

 
17
THIS FORM DOES NOT CONSTITUTE LEGAL ADVICE. LEGAL ADVICE IS
18
DEPENDENT ON THE SPECIFIC CIRCUMSTANCES OF EACH SITUATION AND
19
JURISDICTION. THE INFORMATION IN THIS FORM CANNOT REPLACE THE
20
ADVICE OF AN ATTORNEY LICENSED IN YOUR STATE.
21    As a birth parent in the State of Illinois, you have the
22right:
23    1. To have your own attorney represent you. The prospective

 

 

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1adoptive parents may agree to pay for the cost of your attorney
2in a manner consistent with Illinois law, but they are not
3required to do so.
4    2. To be treated with dignity and respect at all times and
5to make decisions free from coercion and pressure.
6    3. To request to receive counseling before and after
7signing a Final and Irrevocable Consent to Adoption
8("Consent"), a Final and Irrevocable Consent to Adoption by a
9Specified Person or Persons: Non-DCFS Case ("Specified
10Consent"), or a Consent to Adoption of Unborn Child ("Unborn
11Consent"). The prospective adoptive parents may agree to pay
12for the cost of counseling in a manner consistent with Illinois
13law, but they are not required to do so.
14    4. To ask to be involved in choosing your child's
15prospective adoptive parents and to ask to meet them.
16    5. To ask your child's prospective adoptive parents any
17questions that pertain to your decision to place your child
18with them.
19    6. To see your child before signing a Consent or Specified
20Consent if you are the custodial parent, and to request to see
21your child if you are not the custodial parent.
22    7. To request contact with your child and/or the child's
23prospective adoptive parents, with the understanding that any
24promises regarding contact with your child or receipt of
25information about the child after signing a Consent, Specified
26Consent, or Unborn Consent cannot be enforced under Illinois

 

 

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1law.
2    8. To receive copies of all documents that you sign and
3have those documents provided to you in your preferred
4language.
5    9. To request that your identifying information remain
6confidential, unless required otherwise by Illinois law or
7court order, and to voluntarily share your medical, background,
8and identifying information, including information on the
9original birth certificate of your child. This can be done
10through the Illinois Adoption Registry and Medical Information
11Exchange or through completing the Birth Parent Preference
12Form. Please visit http://dph.illinois.gov or
13www.newillinoisadoptionlaw.com.
14    10. To access the Confidential Intermediary Program which
15provides a way for a court appointed person to connect and/or
16exchange information between adoptees, adoptive parents and
17birth parents, and other biological family members, provided in
18most cases that mutual consent is given. Please visit
19www.ci-illinois.org or call (800) 526-9022(x29).
20    11. To work with an adoption agency or attorney of your
21choice, or change said agency or attorney, provided you
22promptly inform all of the parties currently involved.
23    12. To receive, upon request, a written list of any
24promised support, financial or otherwise, from your attorney or
25the attorney for your child's prospective adoptive parents.
26    13. To delay signing a Consent, Specified Consent, or

 

 

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1Unborn Consent if you are not ready to do so.
2    14. To decline to sign a Consent, Specified Consent, or
3Unborn Consent even if you have received financial support from
4the prospective adoptive parents.
5    If you do not receive any of the rights described in this
6Form, it shall not be a basis to revoke a Consent, Specified
7Consent, or Unborn Consent.
8    As a Birth Parent in the State of Illinois, you have the
9responsibility:
10    1. To carefully consider your reasons for choosing
11adoption.
12    2. (Birth mothers only) To accurately complete an Affidavit
13of Identification, which identifies the father of the child
14when known, with the understanding that a birth mother has a
15right to decline to identify the birth father.
16    3. To provide the necessary documentation regarding
17financial need to make an appropriate determination of
18reasonable pregnancy-related expenses.
19    4. To not accept financial support or reimbursement of
20pregnancy related expenses simultaneously from more than one
21source or if you are not pregnant, as doing so is a crime.
22    5. To voluntarily provide all known medical, background,
23and family information about yourself and your immediate family
24to your child's prospective adoptive parents or their attorney.
25For the health of your child, you are strongly encouraged, but
26not required, to do so as set forth on the following form:

 

 

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1
Birth Parent Medical Information
2    The purpose of this form is to gather your health history,
3genetic history, and social background information to share
4with the adoptive parents. It is important the adoptive family
5provide this information to the child's physician. It will
6become a part of the child's medical and family history. This
7form, in its entirety, will be given to the adoptive parent(s).
8    The following information is true and complete to the best
9of my knowledge and belief.
10    Birth parent name:
11......................................
12    Signature:
13..............................................
14    Date:....................................................
15    YES or NO (circle one) I agree to release my full name on
16this form to the adoptive family. If NO is circled then the
17birth parent's name shall be redacted on this form.
18    MOTHER'S PHYSICAL CHARACTERISTICS:
19Eyes: ... Hair: .... Complexion: .... Height: ....
20Weight: .... Body build: ..... Race: .....
21Nationality/Descent: ....... Blood type: .... Rh factor: ....
22Eye glasses or contact lenses? Yes /.../ No /.../
23Right /.../ Left /.../ handed
24Age: .... or Date of birth: ..... Religion: .................
25    Please list your highest education level, occupation,
26hobbies, interests, and talents:

 

 

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1............................
2Existence of any disabilities? Yes /.../ No /.../
3If yes, explain:.............................................
4    If you have other children, list them below. Include any
5children previously placed for adoption.
6....................
7    Describe your relationship with the birth father: .......
8    FATHER'S PHYSICAL CHARACTERISTICS:
9Eyes: ... Hair: .... Complexion: .... Height: ....
10Weight: .... Body build: ..... Race: .....
11Nationality/Descent: ....... Blood type: .... Rh factor: ....
12Eye glasses or contact lenses? Yes /.../ No /.../
13Right /.../ Left /.../ handed
14Age: .... or Date of birth: ..... Religion: .................
15    Please list your highest education level, occupation,
16hobbies, interests, and talents:
17............................
18Existence of any disabilities? Yes /.../ No /.../
19If yes, explain:.............................................
20    If you have other children, list them below. Include any
21children previously placed for adoption.
22....................
23
PREGNANCY HISTORY INVOLVING THIS CHILD
24    Month prenatal care began during this pregnancy:.........
25    Complications during pregnancy: Yes ... No ... If yes,
26explain: ....................................................

 

 

 

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1    .............................................................
2
MEDICATION AND OTHER SUBSTANCES USED DURING
3
PREGNANCY OR YEAR PRIOR TO PREGNANCY
4FREQUENCY/ FREQUENCY/
5AMOUNT AMOUNT
6DURING PRIOR TO
7YES NO PREGNANCY PREGNANCY
8Alcohol/../ /../................. ...............
9Amphetamines/../ /../................................
10Barbiturates/../ /../................................
11Cocaine/../ /../................................
12Heroin/../ /../................................
13LSD/../ /../................................
14Marijuana/../ /../ ................. ...............
15Caffeine
16(Coffee,
17tea, etc)/../ /../ ................................
18Prescription
19drugs/../ /../ ................. ...............
20Non-
21prescription
22drugs /../ /../................................
23Other /../ /../ ................. ...............
24    In addition to this form, a birth parent shall also be
25provided the forms for the Illinois Adoption Registry and

 

 

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1Medical Information Exchange.
2    B. The form of consent required for the adoption of an
3unborn child shall be substantially as follows:
 
4
CONSENT TO ADOPTION OF UNBORN CHILD

 
5    I, ...., state:
6    That I am the father of a child expected to be born on or
7about .... to .... (name of mother).
8    That I reside at .... County of ...., and State of .....
9    That I am of the age of .... years.
10    That I hereby enter my appearance in such adoption
11proceeding and waive service of summons on me.
12    That I hereby acknowledge that I have been provided with a
13copy of the Birth Parent Rights and Responsibilities-Private
14Form before signing this Consent, and that I have had time to
15read, or have had read to me, this Form. I understand that if I
16do not receive any of the rights as described in this Form, it
17shall not constitute a basis to revoke this Consent to Adoption
18of Unborn Child.
19    That I do hereby consent and agree to the adoption of such
20child, and that I have not previously executed a consent or
21surrender with respect to such child.
22    That I wish to and do understand that by signing this
23consent I do irrevocably and permanently give up all custody
24and other parental rights I have to such child, except that I

 

 

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1have the right to revoke this consent by giving written notice
2of my revocation not later than 72 hours after the birth of the
3child.
4    That I understand such child will be placed for adoption
5and that, except as hereinabove provided, I cannot under any
6circumstances, after signing this document, change my mind and
7revoke or cancel this consent or obtain or recover custody or
8any other rights over such child.
9    That I have read and understand the above and I am signing
10it as my free and voluntary act.
11    Dated (insert date).
12........................
 
13    B-5. (1) The parent of a child may execute a consent to
14standby adoption by a specified person or persons. A consent
15under this subsection B-5 shall be acknowledged by a parent
16pursuant to subsection H and subsection K of this Section. The
17form of consent required for the standby adoption of a born
18child effective at a future date when the consenting parent of
19the child dies or requests that a final judgment of adoption be
20entered shall be substantially as follows:
 
21
FINAL AND IRREVOCABLE CONSENT
22
TO STANDBY ADOPTION

 
23    I, ..., (relationship, e.g. mother or father) of ...., a

 

 

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1..male or female (circle one) child, state:
2    That the child was born on .... at .....
3    That I reside at ...., County of ...., and State of .....
4    That I am of the age of .... years.
5    That I hereby enter my appearance in this proceeding and
6waive service of summons on me in this action only.
7    That I do hereby consent and agree to the standby adoption
8of the child, and that I have not previously executed a consent
9or surrender with respect to the child.
10    That I wish to and understand that by signing this consent
11I do irrevocably and permanently give up all custody and other
12parental rights I have to the child, effective upon (my death)
13(the child's other parent's death) or upon (my) (the other
14parent's) request for the entry of a final judgment for
15adoption if ..... (specified person or persons) adopt my child.
16    That I understand that until (I die) (the child's other
17parent dies), I retain all legal rights and obligations
18concerning the child, but at that time, I irrevocably give all
19custody and other parental rights to .... (specified person or
20persons).
21    I understand my child will be adopted by ....... (specified
22person or persons) only and that I cannot, under any
23circumstances, after signing this document, change my mind and
24revoke or cancel this consent or obtain or recover custody or
25any other rights over my child if ..... (specified person or
26persons) adopt my child.

 

 

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1    I understand that this consent to standby adoption is valid
2only if the petition for standby adoption is filed and that if
3....... (specified person or persons), for any reason, cannot
4or will not file a petition for standby adoption or if his,
5her, or their petition for standby adoption is denied, then
6this consent is void. I have the right to notice of any other
7proceeding that could affect my parental rights.
8    That I have read and understand the above and I am signing
9it as my free and voluntary act.
10    Dated (insert date).
11....................
 
12    If under Section 8 the consent of more than one person is
13required, then each such person shall execute a separate
14consent. A separate consent shall be executed for each child.
15    (2) If the parent consents to a standby adoption by 2
16specified persons, then the form shall contain 2 additional
17paragraphs in substantially the following form:
18    If .... (specified persons) obtain a judgment of
19dissolution of marriage before the judgment for adoption is
20entered, then ..... (specified person) shall adopt my child. I
21understand that I cannot change my mind and revoke this consent
22or obtain or recover custody of my child if ..... (specified
23persons) obtain a judgment of dissolution of marriage and .....
24(specified person) adopts my child. I understand that I cannot
25change my mind and revoke this consent if ...... (specified

 

 

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1persons) obtain a judgment of dissolution of marriage before
2the adoption is final. I understand that this consent to
3adoption has no effect on who will get custody of my child if
4..... (specified persons) obtain a judgment of dissolution of
5marriage after the adoption is final. I understand that if
6either ..... (specified persons) dies before the petition to
7adopt my child is granted, then the surviving person may adopt
8my child. I understand that I cannot change my mind and revoke
9this consent or obtain or recover custody of my child if the
10surviving person adopts my child.
11    A consent to standby adoption by specified persons on this
12form shall have no effect on a court's determination of custody
13or visitation under the Illinois Marriage and Dissolution of
14Marriage Act if the marriage of the specified persons is
15dissolved before the adoption is final.
16    (3) The form of the certificate of acknowledgement for a
17Final and Irrevocable Consent for Standby Adoption shall be
18substantially as follows:
 
19STATE OF .....)
20              ) SS.
21COUNTY OF ....)
 
22    I, ....... (name of Judge or other person) ..... (official
23title, name, and address), certify that ......., personally
24known to me to be the same person whose name is subscribed to

 

 

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1the foregoing Final and Irrevocable Consent to Standby
2Adoption, appeared before me this day in person and
3acknowledged that (she) (he) signed and delivered the consent
4as (her) (his) free and voluntary act, for the specified
5purpose.
6    I have fully explained that this consent to adoption is
7valid only if the petition to adopt is filed, and that if the
8specified person or persons, for any reason, cannot or will not
9adopt the child or if the adoption petition is denied, then
10this consent will be void. I have fully explained that if the
11specified person or persons adopt the child, by signing this
12consent (she) (he) is irrevocably and permanently
13relinquishing all parental rights to the child, and (she) (he)
14has stated that such is (her) (his) intention and desire.
15    Dated (insert date).
16    Signature ..............................
 
17    (4) If a consent to standby adoption is executed in this
18form, the consent shall be valid only if the specified person
19or persons adopt the child. The consent shall be void if:
20        (a) the specified person or persons do not file a
21    petition for standby adoption of the child; or
22        (b) a court denies the standby adoption petition.
23    The parent shall not need to take further action to revoke
24the consent if the standby adoption by the specified person or
25persons does not occur, notwithstanding the provisions of

 

 

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1Section 11 of this Act.
2    C. The form of surrender to any agency given by a parent of
3a born child who is to be subsequently placed for adoption
4shall be substantially as follows and shall contain such other
5facts and statements as the particular agency shall require.
 
6
FINAL AND IRREVOCABLE SURRENDER
7
FOR PURPOSES OF ADOPTION

 
8    I, .... (relationship, e.g., mother, father, relative,
9guardian) of ...., a ..male or female (circle one) child,
10state:
11    That such child was born on ...., at .....
12    That I reside at ...., County of ...., and State of .....
13    That I am of the age of .... years.
14    That I do hereby surrender and entrust the entire custody
15and control of such child to the .... (the "Agency"), a
16(public) (licensed) child welfare agency with its principal
17office in the City of ...., County of .... and State of ....,
18for the purpose of enabling it to care for and supervise the
19care of such child, to place such child for adoption and to
20consent to the legal adoption of such child.
21    That I hereby grant to the Agency full power and authority
22to place such child with any person or persons it may in its
23sole discretion select to become the adopting parent or parents
24and to consent to the legal adoption of such child by such

 

 

HB5155- 22 -LRB100 16596 HEP 35707 b

1person or persons; and to take any and all measures which, in
2the judgment of the Agency, may be for the best interests of
3such child, including authorizing medical, surgical and dental
4care and treatment including inoculation and anaesthesia for
5such child.
6    That I wish to and understand that by signing this
7surrender I do irrevocably and permanently give up all custody
8and other parental rights I have to such child.
9    That I understand I cannot under any circumstances, after
10signing this surrender, change my mind and revoke or cancel
11this surrender or obtain or recover custody or any other rights
12over such child.
13    That I have read and understand the above and I am signing
14it as my free and voluntary act.
15    Dated (insert date).
16........................
 
17    C-5. The form of a Final and Irrevocable Designated
18Surrender for Purposes of Adoption to any agency given by a
19parent of a born child who is to be subsequently placed for
20adoption is to be used by legal parents only. The form shall be
21substantially as follows and shall contain such other facts and
22statements as the particular agency shall require:
 
23
FINAL AND IRREVOCABLE DESIGNATED SURRENDER
24
FOR PURPOSES OF ADOPTION

 

 

 

HB5155- 23 -LRB100 16596 HEP 35707 b

1    I, .... (relationship, e.g., mother, father, relative,
2guardian) of ...., a ..male or female (circle one) child,
3state:
4    1. That such child was born on ...., at .....
5    2. That I reside at ...., County of ...., and State of
6....., my email address (if I have one) is .... my cell phone
7number where I can receive text messages (if I have one) is
8.... and my land line phone number (if I have one) is ...., and
9any other contact information is ....
10    3. That I am of the age of .... years.
11    4. That I do hereby surrender and entrust the entire
12custody and control of such child to the .... (the "Agency"), a
13(public) (licensed) child welfare agency with its principal
14office in the City of ...., County of .... and State of ....,
15for the purpose of enabling it to care for and supervise the
16care of such child, to place such child for adoption with
17............................. (specified person or persons)
18and to consent to the legal adoption of such child and to take
19any and all measures which, in the judgment of the Agency, may
20be for the best interests of such child, including authorizing
21medical, surgical and dental care and treatment including
22inoculation and anesthesia for such child. If only first names
23are used for the specified person or persons, I voluntarily
24sign this designated surrender without disclosure to me of the
25last name of the specified person or persons. However, I

 

 

HB5155- 24 -LRB100 16596 HEP 35707 b

1understand that if I wish to know the last name of the
2specified person or persons, I may request it before signing
3the form. If I do not receive the last name, I may choose not to
4sign the designated surrender form.
5    5. That I wish to and understand that by signing this
6surrender I do irrevocably and permanently give up all custody
7and other parental rights I have to such child.
8    6. That if the petition for adoption is not filed by the
9specified person or persons designated herein or, if the
10petition for adoption is filed but the adoption petition is
11dismissed with prejudice or the adoption proceeding is
12otherwise concluded without an order declaring the child to be
13the adopted child of each specified person, then I understand
14that the Agency will send provide notice to me at the mailing
15address, at the email address, through a text message to my
16cell phone number provided in paragraph 2, and to any other
17contact information I have provided in paragraph 2 within 5 10
18business days of this occurrence. The person sending the notice
19shall prepare an affidavit of notice and that such notice will
20be directed to me using the contact information I have provided
21to the Agency. I understand that I will have 15 10 business
22days from the date that the written notice was sent that the
23Agency sends me its notice to respond, within which time I may
24choose to designate other adoptive parent(s). However, I
25acknowledge that the Agency has full power and authority to
26place the child for adoption with any person or persons it may

 

 

HB5155- 25 -LRB100 16596 HEP 35707 b

1in its sole discretion select to become the adopting parent or
2parents and to consent to the legal adoption of the child by
3such person or persons.
4    7. That I acknowledge that this surrender is valid even if
5the specified persons separate or divorce or one of the
6specified persons dies prior to the entry of the final judgment
7for adoption.
8    8. That I expressly acknowledge that the above paragraphs 6
9and 7 do not impair the validity and absolute finality of this
10surrender under any circumstance.
11    9. That I understand that I have a remaining obligation to
12keep the Agency informed of my current contact information
13until the adoption of the child has been finalized if I wish to
14be notified in the event the adoption by the specified
15person(s) cannot proceed.
16    10. That I understand I cannot under any circumstances,
17after signing this surrender, change my mind and revoke or
18cancel this surrender or obtain or recover custody or any other
19rights over such child.
20    11. That I have read and understand the above and I am
21signing it as my free and voluntary act.
22    Dated (insert date).
23..............................
 
24    D. The form of surrender to an agency given by a parent of
25an unborn child who is to be subsequently placed for adoption

 

 

HB5155- 26 -LRB100 16596 HEP 35707 b

1shall be substantially as follows and shall contain such other
2facts and statements as the particular agency shall require.
 
3
SURRENDER OF UNBORN CHILD FOR
4
PURPOSES OF ADOPTION

 
5    I, .... (father), state:
6    That I am the father of a child expected to be born on or
7about .... to .... (name of mother).
8    That I reside at ...., County of ...., and State of .....
9    That I am of the age of .... years.
10    That I do hereby surrender and entrust the entire custody
11and control of such child to the .... (the "Agency"), a
12(public) (licensed) child welfare agency with its principal
13office in the City of ...., County of .... and State of ....,
14for the purpose of enabling it to care for and supervise the
15care of such child, to place such child for adoption and to
16consent to the legal adoption of such child, and that I have
17not previously executed a consent or surrender with respect to
18such child.
19    That I hereby grant to the Agency full power and authority
20to place such child with any person or persons it may in its
21sole discretion select to become the adopting parent or parents
22and to consent to the legal adoption of such child by such
23person or persons; and to take any and all measures which, in
24the judgment of the Agency, may be for the best interests of

 

 

HB5155- 27 -LRB100 16596 HEP 35707 b

1such child, including authorizing medical, surgical and dental
2care and treatment, including inoculation and anaesthesia for
3such child.
4    That I wish to and understand that by signing this
5surrender I do irrevocably and permanently give up all custody
6and other parental rights I have to such child.
7    That I understand I cannot under any circumstances, after
8signing this surrender, change my mind and revoke or cancel
9this surrender or obtain or recover custody or any other rights
10over such child, except that I have the right to revoke this
11surrender by giving written notice of my revocation not later
12than 72 hours after the birth of such child.
13    That I have read and understand the above and I am signing
14it as my free and voluntary act.
15    Dated (insert date).
16........................
 
17    E. The form of consent required from the parents for the
18adoption of an adult, when such adult elects to obtain such
19consent, shall be substantially as follows:
 
20
CONSENT

 
21    I, ...., (father) (mother) of ...., an adult, state:
22    That I reside at ...., County of .... and State of .....
23    That I do hereby consent and agree to the adoption of such

 

 

HB5155- 28 -LRB100 16596 HEP 35707 b

1adult by .... and .....
2    Dated (insert date).
3.........................
 
4    F. The form of consent required for the adoption of a child
5of the age of 14 years or over, or of an adult, to be given by
6such person, shall be substantially as follows:
 
7
CONSENT

 
8    I, ...., state:
9    That I reside at ...., County of .... and State of .....
10That I am of the age of .... years. That I hereby enter my
11appearance in this proceeding and waive service of summons on
12me. That I consent and agree to my adoption by .... and .....
13    Dated (insert date).
14........................
 
15    G. The form of consent given by an agency to the adoption
16by specified persons of a child previously surrendered to it
17shall set forth that the agency has the authority to execute
18such consent. The form of consent given by a guardian of the
19person of a child sought to be adopted, appointed by a court of
20competent jurisdiction, shall set forth the facts of such
21appointment and the authority of the guardian to execute such
22consent.

 

 

HB5155- 29 -LRB100 16596 HEP 35707 b

1    H. A consent (other than that given by an agency, or
2guardian of the person of the child sought to be adopted who
3was appointed by a court of competent jurisdiction) shall be
4acknowledged by a parent before a judge of a court of competent
5jurisdiction or, except as otherwise provided in this Act,
6before a representative of an agency, or before a person, other
7than the attorney for the prospective adoptive parent or
8parents, designated by a court of competent jurisdiction.
9    I. A surrender, or any other document equivalent to a
10surrender, by which a child is surrendered to an agency shall
11be acknowledged by the person signing such surrender, or other
12document, before a judge of a court of competent jurisdiction,
13or, except as otherwise provided in this Act, before a
14representative of an agency, or before a person designated by a
15court of competent jurisdiction.
16    J. The form of the certificate of acknowledgment for a
17consent, a surrender, or any other document equivalent to a
18surrender, shall be substantially as follows:
 
19STATE OF ....)
20             ) SS.
21COUNTY OF ...)
22    I, .... (Name of judge or other person), .... (official
23title, name and location of court or status or position of
24other person), certify that ...., personally known to me to be
25the same person whose name is subscribed to the foregoing

 

 

HB5155- 30 -LRB100 16596 HEP 35707 b

1(consent) (surrender), appeared before me this day in person
2and acknowledged that (she) (he) signed and delivered such
3(consent) (surrender) as (her) (his) free and voluntary act,
4for the specified purpose.
5    I have fully explained that by signing such (consent)
6(surrender) (she) (he) is irrevocably relinquishing all
7parental rights to such child or adult and (she) (he) has
8stated that such is (her) (his) intention and desire. (Add if
9Consent only) I am further satisfied that, before signing this
10Consent, ........ has read, or has had read to him or her, the
11Birth Parent Rights and Responsibilities-Private Form.
12    Dated (insert date).
13    Signature ...............
 
14    K. When the execution of a consent or a surrender is
15acknowledged before someone other than a judge, such other
16person shall have his or her signature on the certificate
17acknowledged before a notary public, in form substantially as
18follows:
 
19STATE OF ....)
20             ) SS.
21COUNTY OF ...)
22    I, a Notary Public, in and for the County of ......, in the
23State of ......, certify that ...., personally known to me to
24be the same person whose name is subscribed to the foregoing

 

 

HB5155- 31 -LRB100 16596 HEP 35707 b

1certificate of acknowledgment, appeared before me in person and
2acknowledged that (she) (he) signed such certificate as (her)
3(his) free and voluntary act and that the statements made in
4the certificate are true.
5    Dated (insert date).
6    
Signature ...................... Notary Public
7
(official seal)

 
8    There shall be attached a certificate of magistracy, or
9other comparable proof of office of the notary public
10satisfactory to the court, to a consent signed and acknowledged
11in another state.
12    L. A surrender or consent executed and acknowledged outside
13of this State, either in accordance with the law of this State
14or in accordance with the law of the place where executed, is
15valid.
16    M. Where a consent or a surrender is signed in a foreign
17country, the execution of such consent shall be acknowledged or
18affirmed in a manner conformable to the law and procedure of
19such country.
20    N. If the person signing a consent or surrender is in the
21military service of the United States, the execution of such
22consent or surrender may be acknowledged before a commissioned
23officer and the signature of such officer on such certificate
24shall be verified or acknowledged before a notary public or by
25such other procedure as is then in effect for such division or

 

 

HB5155- 32 -LRB100 16596 HEP 35707 b

1branch of the armed forces.
2    O. (1) The parent or parents of a child in whose interests
3a petition under Section 2-13 of the Juvenile Court Act of 1987
4is pending may, with the approval of the designated
5representative of the Department of Children and Family
6Services ("Department" or "DCFS"), execute a consent to
7adoption by a specified person or persons:
8        (a) in whose physical custody the child has resided for
9    at least 6 months; or
10        (b) in whose physical custody at least one sibling of
11    the child who is the subject of this consent has resided
12    for at least 6 months, and the child who is the subject of
13    this consent is currently residing in this foster home; or
14        (c) in whose physical custody a child under one year of
15    age has resided for at least 3 months.
16    The court may waive the time frames in subdivisions (a),
17(b), and (c) for good cause shown if the court finds it to be in
18the child's best interests.
19    A consent under this subsection O shall be acknowledged by
20a parent pursuant to subsection H and subsection K of this
21Section.
22    (2) The final and irrevocable consent to adoption by a
23specified person or persons in a Department of Children and
24Family Services (DCFS) case shall be substantially as follows:
 
25
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY

 

 

HB5155- 33 -LRB100 16596 HEP 35707 b

1
A SPECIFIED PERSON OR PERSONS: DCFS CASE

 
2    I, ......................................, the
3.................. (mother or father (circle one) of a ....male
4or female (circle one) child, state:
5        1. My child ............................ (name of
6    child) was born on ..... (insert date) at
7    .................... Hospital in the City/Town
8    municipality of ........., in ................ County,
9    State of ...............
10        2. I reside at ......................, County of
11    ............. and State of ..............
12        Mail may also be sent to me at this address
13    ............................, in care of .................
14        My home telephone number is......................
15        My cell telephone number is......................
16        My e-mail address is.................................
17        3. I, ..........................., am .... years old.
18        4. I enter my appearance in this action for my child to
19    be adopted by the person or persons specified herein by me
20    and waive service of summons on me in this action only.
21        5. I hereby acknowledge that I have been provided a
22    copy of the Birth Parent Rights and Responsibilities in
23    Illinois for Final and Irrevocable Consents to Adoption by
24    a Specified Person or Persons for DCFS Cases before signing
25    this Consent and that I have had time to read this form or

 

 

HB5155- 34 -LRB100 16596 HEP 35707 b

1    have it read to me and that I understand the rights and
2    responsibilities described in this form. I understand that
3    if I do not receive any of my rights as described in the
4    form, it shall not constitute a basis to revoke this Final
5    and Irrevocable Consent to Adoption by a Specified Person
6    or Persons.
7        6. I do hereby consent and agree to the adoption of
8    such child by .......... (names of current foster parent(s)
9    or caregiver(s), hereinafter referred to as the
10    " (specified person or persons") only.
11        7. I wish to sign this consent and I understand that by
12    signing this consent I irrevocably and permanently give up
13    all my parental rights I have to my child.
14        8. I understand that this consent allows my child to be
15    adopted by the specified person or persons .......... only
16    and that I cannot under any circumstances after signing
17    this document change my mind and revoke or cancel this
18    consent.
19        9. I understand that this consent will be void if:
20            (a) the Department places my child with someone
21        other than the specified person or persons; or
22            (b) a court denies the adoption petition for the
23        specified person or persons to adopt my child; or
24            (c) the DCFS Guardianship Administrator refuses to
25        consent to my child's adoption by the specified person
26        or persons on the basis that the adoption is not in my

 

 

HB5155- 35 -LRB100 16596 HEP 35707 b

1        child's best interests.
2        I understand that if this consent is void I have
3    parental rights to my child, subject to any applicable
4    court orders including those entered under Article II of
5    the Juvenile Court Act of 1987, unless and until I sign a
6    new consent or surrender or my parental rights are
7    involuntarily terminated. I understand that if this
8    consent is void, my child may be adopted by someone other
9    than the specified person or persons only if I sign a new
10    consent or surrender, or my parental rights are
11    involuntarily terminated. I understand that if this
12    consent is void, the Department will notify me within 30
13    days using the addresses and telephone numbers I provided
14    in paragraph 2 of this form. I understand that if I receive
15    such a notice, it is very important that I contact the
16    Department immediately, and preferably within 30 days, to
17    have input into the plan for my child's future.
18        10. I understand that if a petition for adoption of my
19    child is filed by someone other than the specified person
20    or persons, the Department will notify me within 14 days
21    after the Department becomes aware of the petition. The
22    fact that someone other than the specified person or
23    persons files a petition to adopt my child does not make
24    this consent void.
25        11. If a person other than the specified person or
26    persons files a petition to adopt my child or if the

 

 

HB5155- 36 -LRB100 16596 HEP 35707 b

1    consent is void under paragraph 9, the Department will send
2    written notice to me using the mailing address and email
3    address provided by me in paragraph 2 of this form. The
4    Department will also contact me using the telephone numbers
5    I provided in paragraph 2 of this form. It is very
6    important that I let the Department know if any of my
7    contact information changes. If I do not let the Department
8    know if any of my contact information changes, I understand
9    that I may not receive notification from the Department if
10    this consent is void or if someone other than the specified
11    person or persons files a petition to adopt my child. If
12    any of my contact information changes, I should immediately
13    notify:
14        Caseworker's name and telephone number:
15    ............................................................;
16        Agency name, address, zip code, and telephone number:
17    ............................................................;
18        Supervisor's name and telephone number:
19    ............................................................;
20    DCFS Advocacy Office for Children and Families:
21    800-232-3798.
22        12. I expressly acknowledge that paragraph 9 (and
23    paragraphs 8a and 8b, if applicable) do not impair the
24    validity and finality of this consent under any
25    circumstances.
26        13. I have read and understand the above and I am

 

 

HB5155- 37 -LRB100 16596 HEP 35707 b

1    signing it as my free and voluntary act.
2        Dated (insert date).
3        .............................................
4        Signature of parent
 
5    (3) If the parent consents to an adoption by 2 specified
6persons, then the form shall contain 2 additional paragraphs in
7substantially the following form:
8        8a. If ............... (specified persons) get a
9    divorce or are granted a dissolution of a civil union
10    before the petition to adopt my child is granted, this
11    consent is valid for ........... (specified person) to
12    adopt my child. I understand that I cannot change my mind
13    or revoke this consent or recover custody of my child on
14    the basis that the specified persons divorce or are granted
15    a dissolution of a civil union or that one of the specified
16    persons has died.
17        8b. I understand that if the specified persons get a
18    divorce or are granted a dissolution of a civil union
19    before the petition to adopt my child is granted, this
20    consent remains valid only for either ...............
21    (name only one specified person) to adopt my child
22    (specified persons) dies before the petition to adopt my
23    child is granted, this consent remains valid for the
24    surviving person to adopt my child. I understand that I
25    cannot change my mind or revoke this consent or recover

 

 

HB5155- 38 -LRB100 16596 HEP 35707 b

1    custody of my child on the basis that one of the specified
2    persons dies.
3        8c. I understand that if either of the specified
4    persons dies before the petition to adopt my child is
5    granted, this consent remains valid for the surviving
6    person to adopt my child.
7    (4) The form of the certificate of acknowledgement for a
8Final and Irrevocable Consent for Adoption by a Specified
9Person or Persons: DCFS Case shall be substantially as follows:
 
10STATE OF ..............)
11                       ) SS.
12COUNTY OF .............)
 
13    I, .................... (Name of Judge or other person),
14..................... (official title, name, and address),
15certify that ............., personally known to me to be the
16same person whose name is subscribed to the foregoing Final and
17Irrevocable Consent for Adoption by a Specified Person or
18Persons: DCFS Case, appeared before me this day in person and
19acknowledged that (she)(he) signed and delivered the consent as
20(her)(his) free and voluntary act, for the specified purpose.
21    I have fully explained that by signing this consent this
22parent is irrevocably and permanently relinquishing all
23parental rights to the child so that the child may be adopted
24by a specified person or persons, and this parent has stated

 

 

HB5155- 39 -LRB100 16596 HEP 35707 b

1that such is (her)(his) intention and desire. I have fully
2explained that this consent is void only if:
3        (a) the placement is disrupted and the child is moved
4    to a different placement; or
5        (b) a court denies the petition for adoption; or
6        (c) the Department of Children and Family Services
7    Guardianship Administrator refuses to consent to the
8    child's adoption by a specified person or persons on the
9    basis that the adoption is not in the child's best
10    interests.
11    Dated (insert date).
12    ...............................
13    Signature
 
14    (5) If a consent to adoption by a specified person or
15persons is executed in this form, the following provisions
16shall apply. The consent shall be valid only for the specified
17person or persons to adopt the child. The consent shall be void
18if:
19        (a) the placement disrupts and the child is moved to
20    another placement; or
21        (b) a court denies the petition for adoption; or
22        (c) the Department of Children and Family Services
23    Guardianship Administrator refuses to consent to the
24    child's adoption by the specified person or persons on the
25    basis that the adoption is not in the child's best

 

 

HB5155- 40 -LRB100 16596 HEP 35707 b

1    interests.
2    If the consent is void under this Section, the parent shall
3not need to take further action to revoke the consent. No
4proceeding for termination of parental rights shall be brought
5unless the parent who executed the consent to adoption by a
6specified person or persons has been notified of the
7proceedings pursuant to Section 7 of this Act or subsection (4)
8of Section 2-13 of the Juvenile Court Act of 1987.
9    (6) The Department of Children and Family Services is
10authorized to promulgate rules necessary to implement this
11subsection O.
12    (7) (Blank).
13    (8) The Department of Children and Family Services shall
14promulgate a rule and procedures regarding Consents to Adoption
15by a Specified Person or Persons in DCFS cases. The rule and
16procedures shall provide for the development of the Birth
17Parent Rights and Responsibilities Form for DCFS Cases.
18    (9) A consent to adoption by specified persons on this
19consent form shall have no effect on a court's determination of
20custody or visitation under the Illinois Marriage and
21Dissolution of Marriage Act or the Illinois Religious Freedom
22Protection and Civil Union Act if the marriage or civil union
23of the specified persons is dissolved after the adoption is
24final.
25    P. If the person signing a consent is incarcerated or
26detained in a correctional facility, prison, jail, detention

 

 

HB5155- 41 -LRB100 16596 HEP 35707 b

1center, or other comparable institution, either in this State
2or any other jurisdiction, the execution of such consent may be
3acknowledged before social service personnel of such
4institution, or before a person designated by a court of
5competent jurisdiction.
6    Q. A consent may be acknowledged telephonically, via
7audiovisual connection, or other electronic means, provided
8that a court of competent jurisdiction has entered an order
9approving the execution of the consent in such manner and has
10designated an individual to be physically present with the
11parent executing such consent in order to verify the identity
12of the parent.
13    R. An agency whose representative is acknowledging a
14consent pursuant to this Section shall be a public child
15welfare agency, or a child welfare agency, or a child placing
16agency that is authorized or licensed in the State or
17jurisdiction in which the consent is signed.
18    S. The form of waiver by a putative or legal father of a
19born or unborn child shall be substantially as follows:
 
20
FINAL AND IRREVOCABLE
21
WAIVER OF PARENTAL RIGHTS OF PUTATIVE OR LEGAL FATHER

 
22    I, .................... , state under oath or affirm as
23follows:
24        1. That the biological mother ............... has

 

 

HB5155- 42 -LRB100 16596 HEP 35707 b

1    named me as a possible biological or legal father of her
2    minor child who was born, or is expected to be born on
3    ..........., ......, in the City/Town of........., State
4    of ...........
5        2. That I understand that the biological mother
6    ............. intends to or has placed the child for
7    adoption.
8        3. That I reside at ................, in the City/Town
9    of..........., State of ................
10        4. That I am ................ years of age and my date
11    of birth is ..............., .............
12        5. That I (select one):
13            ..... am married to the biological mother.
14            ..... am not married to the biological mother and
15        have not been married to the biological mother within
16        300 days before the child's birth or expected date of
17        child's birth.
18            ..... am not currently married to the biological
19        mother, but was married to the biological mother,
20        within 300 days before the child's birth or expected
21        date of child's birth.
22        6. That I (select one):
23            ..... neither admit nor deny that I am the
24        biological father of the child.
25            ..... deny that I am the biological father of the
26        child.

 

 

HB5155- 43 -LRB100 16596 HEP 35707 b

1        7. That I hereby agree to the termination of my
2    parental rights, if any, without further notice to me of
3    any proceeding for the adoption of the minor child, even if
4    I have taken any action to establish parental rights or
5    take any such action in the future including registering
6    with any putative father registry.
7        8. That I understand that by signing this Waiver I do
8    irrevocably and permanently give up all custody and other
9    parental rights I may have to such child.
10        9. That I understand that this Waiver is FINAL AND
11    IRREVOCABLE and that I am permanently barred from
12    contesting any proceeding for the adoption of the child
13    after I sign this Waiver.
14        10. That I waive any further service of summons or
15    other pleadings in any proceeding to terminate parental
16    rights, if any to this child, or any proceeding for
17    adoption of this child.
18        11. That I understand that if a final judgment or order
19    of adoption for this child is not entered, then any
20    parental rights or responsibilities that I may have remain
21    intact.
22        12. That I have read and understand the above and that
23    I am signing it as my free and voluntary act.
 
24    Dated: ................... , ..............
25    ...........................................

 

 

HB5155- 44 -LRB100 16596 HEP 35707 b

1    Signature
 
2
OATH
3I have been duly sworn and I state under oath that I have read
4and understood this Final and Irrevocable Waiver of Parental
5Rights of Putative or Legal Father. The facts contained in it
6are true and correct to the best of my knowledge. I have signed
7this document as my free and voluntary act in order to
8facilitate the adoption of the child.
 
9..............................
10Signature
 
11Signed and Sworn before me on
12this ............ day
13of ..........., 20....
 
14...................
15Notary Public
16(Source: P.A. 98-463, eff. 8-16-13; 99-833, eff. 1-1-17.)