Illinois Compiled Statutes 750 ILCS 50/10 – Forms of consent and surrender; execution and acknowledgment thereof
I, …., (relationship, e.g., mother, father, relative, guardian) of …., a male or female (circle one) child, state:
Terms Used In Illinois Compiled Statutes 750 ILCS 50/10
- Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
- Affirmed: In the practice of the appellate courts, the decree or order is declared valid and will stand as rendered in the lower court.
- Dependent: A person dependent for support upon another.
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Oath: A promise to tell the truth.
- oath: shall be deemed to include an affirmation, and the word "sworn" shall be construed to include the word "affirmed. See Illinois Compiled Statutes 5 ILCS 70/1.12
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Pleadings: Written statements of the parties in a civil case of their positions. In the federal courts, the principal pleadings are the complaint and the answer.
- Service of process: The service of writs or summonses to the appropriate party.
- State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
- Summons: Another word for subpoena used by the criminal justice system.
- sworn: shall be construed to include the word "affirmed. See Illinois Compiled Statutes 5 ILCS 70/1.12
- United States: may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
That such child was born on …. at ….
That I reside at …., County of …. and State of ….
That I am of the age of …. years.
That I hereby enter my appearance in this proceeding and waive service of summons on me.
That I hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and Responsibilities-Private Form before signing this Consent and that I have had time to read, or have had read to me, this Form. I understand that if I do not receive any of the rights as described in this Form, it shall not constitute a basis to revoke this Final and Irrevocable Consent.
That I do hereby consent and agree to the adoption of such child.
That I wish to and understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child.
That I understand such child will be placed for adoption and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over such child. That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
…………………….
If under Section 8 the consent of more than one person is required, then each such person shall execute a separate consent.
A-1. (1) The form of the Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case set forth in this subsection A-1 is to be used by legal parents only. This form is not to be used in cases in which there is a pending petition under Section 2-13 of the Juvenile Court Act of 1987.
(2) The form of the Final and Irrevocable Consent to Adoption by a Specified Person or Persons in a non-DCFS case shall have the caption of the proceeding in which it is to be filed and shall be substantially as follows:
I, …., (relationship, e.g., mother, father) of …., a male or female (circle one) child, state:
1. That such child was born on …., at ….., in the City/Town of … and State of ….
2. That I reside at …., County of …. and State of …., my email address (if I have one) is …. my cell phone number where I can receive text messages (if I have one) is …. and my land line phone number (if I have one) is …., and any other contact information is ….
3. That I am of the age of …. years.
4. That I hereby enter my appearance in this proceeding and waive service of summons on me.
5. That I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and Responsibilities-Private Form before signing this Consent and that I have had time to read, or have had read to me, this Form and that I understand the Rights and Responsibilities described in this Form. I understand that if I do not receive any of my rights as described in said Form, it shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person.
6. That I do hereby consent and agree to the adoption of such child by …. (specified person or persons) only. If only first names are used for the specified person or persons, I voluntarily sign this specified consent form without disclosure to me of the last name of the specified person or persons. However, I understand that if I wish to know the last name of the specified person or persons, I may request it before signing the form. If I do not receive the last name, I may choose not to sign the specified consent form.
7. That I wish to and understand that upon signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child if such child is adopted by …. (specified person or persons). I hereby transfer all of my rights to the custody, care and control of such child to ……………………….. (specified person or persons).
8. That I understand such child will be adopted by ………………….. (specified person or persons) and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over such child if ………………………. (specified person or persons) adopt(s) such child; PROVIDED that each specified person has filed or shall file, within 60 days from the date hereof, a petition for the adoption of such child.
9. That if the specified person or persons designated herein do not file a petition for adoption within the time-frame specified above, or, if said petition for adoption is filed within the time-frame specified above but the adoption petition is dismissed with prejudice or the adoption proceeding is otherwise concluded without an order declaring the child to be the adopted child of the specified person or persons, then I understand that I will be sent written notice of such circumstances at the mailing address, at the email address, through a text message to my cell phone number, and to any other contact information I have provided in paragraph 2 within 5 business days of this occurrence. I understand that the notice will be directed to me using the contact information I have provided in this consent. I understand that I will have 15 business days from the date that the written notice is sent to me to respond in the manner described in the notice, within which time I may request the Court to declare this consent voidable and return the child to me. I further understand that the Court will make the final decision of whether or not the child will be returned to me. If I do not make such request within 15 business days of the date the notice was sent, then I expressly waive any other notice or service of process in any legal proceeding regarding the child, including a legal proceeding for someone other than ….. (specified person or persons) to adopt the child, and that I will have no parental rights as to the child. The person sending the notice shall file an affidavit of notice as proof of the date sent.
10. That I expressly acknowledge that nothing in this Consent impairs the validity and absolute finality of this Consent under any circumstance other than those described in paragraph 9 of this Consent.
11. That I understand that I have a remaining duty and obligation to keep ………….. (insert name and address of the attorney for the specified person or persons) informed of my current address or other preferred contact information until this adoption has been finalized. My failure to do so may result in the termination of my parental rights and the child being placed for adoption in another home.
12. That I do expressly waive any other notice or service of process in any of the legal proceedings for the adoption of the child as long as the adoption proceeding by the specified person or persons is pending.
13. That I have read and understand the above and I am signing it as my free and voluntary act.
14. That I acknowledge that this consent is valid even if the specified person or persons separate or divorce or one of the specified persons dies prior to the entry of the final judgment for adoption.
Dated (insert date).
………………………………………
Signature of parent.
………………………………………
Address of parent.
………………………………………
Phone number(s) of parent.
………………………………………
Personal email(s) of parent.
………………………………………
(3) The form of the certificate of acknowledgement for a Final and Irrevocable Consent for Adoption by a Specified Person or Persons: Non-DCFS Case shall be substantially as follows:
STATE OF …………..)
) SS.
COUNTY OF ………….)
I, ……………….. (Name of Judge or other person), ………………… (official title, name, and address), certify that …………., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent for Adoption by a Specified Person or Persons; non-DCFS case, appeared before me this day in person and acknowledged that (she)(he) signed and delivered the consent as (her)(his) free and voluntary act, for the specified purpose. I am further satisfied that, before signing this Consent, …….. has read, or has had read to him or her, the Birth Parent Rights and Responsibilities-Private Form.
A-2. Birth Parent Rights and Responsibilities-Private Form. The Birth Parent Rights and Responsibilities-Private Form must be read by, or have been read to, any person executing a Final and Irrevocable Consent to Adoption under subsection A, a Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case under subsection A-1, or a Consent to Adoption of Unborn Child under subsection B prior to the execution of said Consent. The form of the Birth Parent Rights and Responsibilities-Private Form shall be substantially as follows:
As a birth parent in the State of Illinois, you have the right:
1. To have your own attorney represent you. The prospective adoptive parents may agree to pay for the cost of your attorney in a manner consistent with Illinois law, but they are not required to do so.
2. To be treated with dignity and respect at all times and to make decisions free from coercion and pressure.
3. To request to receive counseling before and after signing a Final and Irrevocable Consent to Adoption (“Consent”), a Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case (“Specified Consent”), or a Consent to Adoption of Unborn Child (“Unborn Consent”). The prospective adoptive parents may agree to pay for the cost of counseling in a manner consistent with Illinois law, but they are not required to do so.
4. To ask to be involved in choosing your child’s prospective adoptive parents and to ask to meet them.
5. To ask your child’s prospective adoptive parents any questions that pertain to your decision to place your child with them.
6. To see your child before signing a Consent or Specified Consent if you are the custodial parent, and to request to see your child if you are not the custodial parent.
7. To request contact with your child and/or the child’s prospective adoptive parents, with the understanding that any promises regarding contact with your child or receipt of information about the child after signing a Consent, Specified Consent, or Unborn Consent cannot be enforced under Illinois law.
8. To receive copies of all documents that you sign and have those documents provided to you in your preferred language.
9. To request that your identifying information remain confidential, unless required otherwise by Illinois law or court order, and to voluntarily share your medical, background, and identifying information, including information on the original birth certificate of your child. This can be done through the Illinois Adoption Registry and Medical Information Exchange or through completing the Birth Parent Preference Form. Please visit http://dph.illinois.gov or www.newillinoisadoptionlaw.com.
10. To access the Confidential Intermediary Program which provides a way for a court appointed person to connect and/or exchange information between adoptees, adoptive parents and birth parents, and other biological family members, provided in most cases that mutual consent is given. Please visit www.ci-illinois.org or call (800) 526-9022(x29).
11. To work with an adoption agency or attorney of your choice, or change said agency or attorney, provided you promptly inform all of the parties currently involved.
12. To receive, upon request, a written list of any promised support, financial or otherwise, from your attorney or the attorney for your child’s prospective adoptive parents.
13. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready to do so.
14. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have received financial support from the prospective adoptive parents.
If you do not receive any of the rights described in this Form, it shall not be a basis to revoke a Consent, Specified Consent, or Unborn Consent.
As a Birth Parent in the State of Illinois, you have the responsibility:
1. To carefully consider your reasons for choosing adoption.
2. (Birth mothers only) To accurately complete an Affidavit of Identification, which identifies the father of the child when known, with the understanding that a birth mother has a right to decline to identify the birth father.
3. To provide the necessary documentation regarding financial need to make an appropriate determination of reasonable pregnancy-related expenses.
4. To not accept financial support or reimbursement of pregnancy related expenses simultaneously from more than one source or if you are not pregnant, as doing so is a crime.
5. To voluntarily provide all known medical, background, and family information about yourself and your immediate family to your child’s prospective adoptive parents or their attorney. For the health of your child, you are strongly encouraged, but not required, to do so as set forth on the following form:
The purpose of this form is to gather your health history, genetic history, and social background information to share with the adoptive parents. It is important the adoptive family provide this information to the child’s physician. It will become a part of the child’s medical and family history. This form, in its entirety, will be given to the adoptive parent(s).
The following information is true and complete to the best of my knowledge and belief.
Birth parent name:
……………………………………………………..
Signature:
……………………………………………………..
Date:……………………………………………..
YES or NO (circle one) I agree to release my full name on this form to the adoptive family. If NO is circled then the birth parent’s name shall be redacted on this form.
MOTHER’S PHYSICAL CHARACTERISTICS:
Eyes: … Hair: …. Complexion: …. Height: ….
Weight: …. Body build: ….. Race: ….. Nationality/Descent: ……. Blood type: …. Rh factor: ….
Eye glasses or contact lenses? Yes /…/ No /…/
Right /…/ Left /…/ handed
Age: …. or Date of birth: ….. Religion: ………………
Please list your highest education level, occupation, hobbies, interests, and talents:
……………………………………………………..
Existence of any disabilities? Yes /…/ No /…/
If yes, explain:……………………………………….
If you have other children, list them below. Include any children previously placed for adoption.
……………………………………………………..
Describe your relationship with the birth father: ……..
FATHER’S PHYSICAL CHARACTERISTICS:
Eyes: … Hair: …. Complexion: …. Height: ….
Weight: …. Body build: ….. Race: ….. Nationality/Descent: ……. Blood type: …. Rh factor: ….
Eye glasses or contact lenses? Yes /…/ No /…/
Right /…/ Left /…/ handed
Age: …. or Date of birth: ….. Religion: ………………
Please list your highest education level, occupation, hobbies, interests, and talents:
……………………………………………………..
Existence of any disabilities? Yes /…/ No /…/
If yes, explain:……………………………………….
If you have other children, list them below. Include any children previously placed for adoption.
……………………………………………………..
Month prenatal care began during this pregnancy:……….
Complications during pregnancy: Yes … No … If yes, explain: .
………………………………………………….
| FREQUENCY/ | FREQUENCY/ | |||
| AMOUNT | AMOUNT | |||
| DURING | PRIOR TO | |||
| YES | NO | PREGNANCY | PREGNANCY | |
| Alcohol | /../ | /../ | ……….. | ………. |
| Amphetamines | /../ | /../ | ……….. | ………. |
| Barbiturates | /../ | /../ | ……….. | ………. |
| Cocaine | /../ | /../ | ……….. | ………. |
| Heroin | /../ | /../ | ……….. | ………. |
| LSD | /../ | /../ | ……….. | ………. |
| Marijuana | /../ | /../ | ……….. | ………. |
| Caffeine | ||||
| (Coffee, | ||||
| tea, etc) | /../ | /../ | ……….. | ………. |
| Prescription | ||||
| drugs | /../ | /../ | ……….. | ………. |
| Non- | ||||
| prescription | ||||
| drugs | /../ | /../ | ……….. | ………. |
| Other | /../ | /../ | ……….. | ………. |
In addition to this form, a birth parent shall also be provided the forms for the Illinois Adoption Registry and Medical Information Exchange.
B. The form of consent required for the adoption of an unborn child shall be substantially as follows:
I, …., state:
That I am the father of a child expected to be born on or about …. to …. (name of mother).
That I reside at …. County of …., and State of …..
That I am of the age of …. years.
That I hereby enter my appearance in such adoption proceeding and waive service of summons on me.
That I hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and Responsibilities-Private Form before signing this Consent, and that I have had time to read, or have had read to me, this Form. I understand that if I do not receive any of the rights as described in this Form, it shall not constitute a basis to revoke this Consent to Adoption of Unborn Child.
That I do hereby consent and agree to the adoption of such child, and that I have not previously executed a consent or surrender with respect to such child.
That I wish to and do understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child, except that I have the right to revoke this consent by giving written notice of my revocation not later than 72 hours after the birth of the child.
That I understand such child will be placed for adoption and that, except as hereinabove provided, I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over such child.
That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
……………………
B-5. (1) The parent of a child may execute a consent to standby adoption by a specified person or persons. A consent under this subsection B-5 shall be acknowledged by a parent pursuant to subsection H and subsection K of this Section. The form of consent required for the standby adoption of a born child effective at a future date when the consenting parent of the child dies or requests that a final judgment of adoption be entered shall be substantially as follows:
I, …, (relationship, e.g. mother or father) of …., a male or female (circle one) child, state:
That the child was born on …. at …..
That I reside at …., County of …., and State of …..
That I am of the age of …. years.
That I hereby enter my appearance in this proceeding and waive service of summons on me in this action only.
That I do hereby consent and agree to the standby adoption of the child, and that I have not previously executed a consent or surrender with respect to the child.
That I wish to and understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to the child, effective upon (my death) (the child’s other parent’s death) or upon (my) (the other parent’s) request for the entry of a final judgment for adoption if ….. (specified person or persons) adopt my child.
That I understand that until (I die) (the child’s other parent dies), I retain all legal rights and obligations concerning the child, but at that time, I irrevocably give all custody and other parental rights to …. (specified person or persons).
I understand my child will be adopted by ……. (specified person or persons) only and that I cannot, under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over my child if ….. (specified person or persons) adopt my child.
I understand that this consent to standby adoption is valid only if the petition for standby adoption is filed and that if ……. (specified person or persons), for any reason, cannot or will not file a petition for standby adoption or if his, her, or their petition for standby adoption is denied, then this consent is void. I have the right to notice of any other proceeding that could affect my parental rights.
That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
………………..
If under Section 8 the consent of more than one person is required, then each such person shall execute a separate consent. A separate consent shall be executed for each child.
(2) If the parent consents to a standby adoption by 2 specified persons, then the form shall contain 2 additional paragraphs in substantially the following form:
If …. (specified persons) obtain a judgment of dissolution of marriage before the judgment for adoption is entered, then ….. (specified person) shall adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody of my child if ….. (specified persons) obtain a judgment of dissolution of marriage and ….. (specified person) adopts my child. I understand that I cannot change my mind and revoke this consent if …… (specified persons) obtain a judgment of dissolution of marriage before the adoption is final. I understand that this consent to adoption has no effect on who will get custody of my child if ….. (specified persons) obtain a judgment of dissolution of marriage after the adoption is final. I understand that if either ….. (specified persons) dies before the petition to adopt my child is granted, then the surviving person may adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody of my child if the surviving person adopts my child.
A consent to standby adoption by specified persons on this form shall have no effect on a court’s determination of custody or visitation under the Illinois Marriage and Dissolution of Marriage Act if the marriage of the specified persons is dissolved before the adoption is final.
(3) The form of the certificate of acknowledgement for a Final and Irrevocable Consent for Standby Adoption shall be substantially as follows:
STATE OF …..)
) SS.
COUNTY OF ….)
I, ……. (name of Judge or other person) ….. (official title, name, and address), certify that ……., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent to Standby Adoption, appeared before me this day in person and acknowledged that (she) (he) signed and delivered the consent as (her) (his) free and voluntary act, for the specified purpose.
I have fully explained that this consent to adoption is valid only if the petition to adopt is filed, and that if the specified person or persons, for any reason, cannot or will not adopt the child or if the adoption petition is denied, then this consent will be void. I have fully explained that if the specified person or persons adopt the child, by signing this consent (she) (he) is irrevocably and permanently relinquishing all parental rights to the child, and (she) (he) has stated that such is (her) (his) intention and desire.
Dated (insert date).
Signature …………………………
(4) If a consent to standby adoption is executed in this form, the consent shall be valid only if the specified person or persons adopt the child. The consent shall be void if:
(a) the specified person or persons do not file a
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petition for standby adoption of the child; or
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The parent shall not need to take further action to revoke the consent if the standby adoption by the specified person or persons does not occur, notwithstanding the provisions of Section 11 of this Act.
C. The form of surrender to any agency given by a parent of a born child who is to be subsequently placed for adoption shall be substantially as follows and shall contain such other facts and statements as the particular agency shall require.
I, …. (relationship, e.g., mother, father, relative, guardian) of …., a male or female (circle one) child, state:
That such child was born on …., at …..
That I reside at …., County of …., and State of …..
That I am of the age of …. years.
That I do hereby surrender and entrust the entire custody and control of such child to the …. (the “Agency”), a (public) (licensed) child welfare agency with its principal office in the City of …., County of …. and State of …., for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption and to consent to the legal adoption of such child.
That I hereby grant to the Agency full power and authority to place such child with any person or persons it may in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of such child by such person or persons; and to take any and all measures which, in the judgment of the Agency, may be for the best interests of such child, including authorizing medical, surgical and dental care and treatment including inoculation and anaesthesia for such child.
That I wish to and understand that by signing this surrender I do irrevocably and permanently give up all custody and other parental rights I have to such child.
That I understand I cannot under any circumstances, after signing this surrender, change my mind and revoke or cancel this surrender or obtain or recover custody or any other rights over such child.
That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
……………………
C-5. The form of a Final and Irrevocable Designated Surrender for Purposes of Adoption to any agency given by a parent of a born child who is to be subsequently placed for adoption is to be used by legal parents only. The form shall be substantially as follows and shall contain such other facts and statements as the particular agency shall require:
I, …. (relationship, e.g., mother, father, relative, guardian) of …., a male or female (circle one) child, state:
1. That such child was born on …., at …..
2. That I reside at …., County of …., and State of ….., my email address (if I have one) is …. my cell phone number where I can receive text messages (if I have one) is …. and my land line phone number (if I have one) is …., and any other contact information is ….
3. That I am of the age of …. years.
4. That I do hereby surrender and entrust the entire custody and control of such child to the …. (the “Agency”), a (public) (licensed) child welfare agency with its principal office in the City of …., County of …. and State of …., for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption with ……………………….. (specified person or persons) and to consent to the legal adoption of such child and to take any and all measures which, in the judgment of the Agency, may be for the best interests of such child, including authorizing medical, surgical and dental care and treatment including inoculation and anesthesia for such child. If only first names are used for the specified person or persons, I voluntarily sign this designated surrender without disclosure to me of the last name of the specified person or persons. However, I understand that if I wish to know the last name of the specified person or persons, I may request it before signing the form. If I do not receive the last name, I may choose not to sign the designated surrender form.
5. That I wish to and understand that by signing this surrender I do irrevocably and permanently give up all custody and other parental rights I have to such child.
6. That if the petition for adoption is not filed by the specified person or persons designated herein or, if the petition for adoption is filed but the adoption petition is dismissed with prejudice or the adoption proceeding is otherwise concluded without an order declaring the child to be the adopted child of each specified person, then I understand that the Agency will send notice to me at the mailing address, at the email address, through a text message to my cell phone number provided in paragraph 2, and to any other contact information I have provided in paragraph 2 within 5 business days of this occurrence. The person sending the notice shall prepare an affidavit of notice. I understand that I will have 15 business days from the date that the written notice was sent to respond, within which time I may choose to designate other adoptive parent(s). However, I acknowledge that the Agency has full power and authority to place the child for adoption with any person or persons it may in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of the child by such person or persons.
7. That I acknowledge that this surrender is valid even if the specified persons separate or divorce or one of the specified persons dies prior to the entry of the final judgment for adoption.
8. That I expressly acknowledge that the above paragraphs 6 and 7 do not impair the validity and absolute finality of this surrender under any circumstance.
9. That I understand that I have a remaining obligation to keep the Agency informed of my current contact information until the adoption of the child has been finalized if I wish to be notified in the event the adoption by the specified person(s) cannot proceed.
10. That I understand I cannot under any circumstances, after signing this surrender, change my mind and revoke or cancel this surrender or obtain or recover custody or any other rights over such child.
11. That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
…………………………
D. The form of surrender to an agency given by a parent of an unborn child who is to be subsequently placed for adoption shall be substantially as follows and shall contain such other facts and statements as the particular agency shall require.
I, …. (father), state:
That I am the father of a child expected to be born on or about …. to …. (name of mother).
That I reside at …., County of …., and State of …..
That I am of the age of …. years.
That I do hereby surrender and entrust the entire custody and control of such child to the …. (the “Agency”), a (public) (licensed) child welfare agency with its principal office in the City of …., County of …. and State of …., for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption and to consent to the legal adoption of such child, and that I have not previously executed a consent or surrender with respect to such child.
That I hereby grant to the Agency full power and authority to place such child with any person or persons it may in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of such child by such person or persons; and to take any and all measures which, in the judgment of the Agency, may be for the best interests of such child, including authorizing medical, surgical and dental care and treatment, including inoculation and anaesthesia for such child.
That I wish to and understand that by signing this surrender I do irrevocably and permanently give up all custody and other parental rights I have to such child.
That I understand I cannot under any circumstances, after signing this surrender, change my mind and revoke or cancel this surrender or obtain or recover custody or any other rights over such child, except that I have the right to revoke this surrender by giving written notice of my revocation not later than 72 hours after the birth of such child.
That I have read and understand the above and I am signing it as my free and voluntary act.
Dated (insert date).
……………………
E. The form of consent required from the parents for the adoption of an adult, when such adult elects to obtain such consent, shall be substantially as follows:
I, …., (father) (mother) of …., an adult, state:
That I reside at …., County of …. and State of …..
That I do hereby consent and agree to the adoption of such adult by …. and …..
Dated (insert date).
…………………….
F. The form of consent required for the adoption of a child of the age of 14 years or over, or of an adult, to be given by such person, shall be substantially as follows:
I, …., state:
That I reside at …., County of …. and State of ….. That I am of the age of …. years. That I hereby enter my appearance in this proceeding and waive service of summons on me. That I consent and agree to my adoption by …. and …..
Dated (insert date).
……………………
G. The form of consent given by an agency to the adoption by specified persons of a child previously surrendered to it shall set forth that the agency has the authority to execute such consent. The form of consent given by a guardian of the person of a child sought to be adopted, appointed by a court of competent jurisdiction, shall set forth the facts of such appointment and the authority of the guardian to execute such consent.
H. A consent (other than that given by an agency, or guardian of the person of the child sought to be adopted who was appointed by a court of competent jurisdiction) shall be acknowledged by a parent before a judge of a court of competent jurisdiction or, except as otherwise provided in this Act, before a representative of an agency, or before a person, other than the attorney for the prospective adoptive parent or parents, designated by a court of competent jurisdiction.
I. A surrender, or any other document equivalent to a surrender, by which a child is surrendered to an agency shall be acknowledged by the person signing such surrender, or other document, before a judge of a court of competent jurisdiction, or, except as otherwise provided in this Act, before a representative of an agency, or before a person designated by a court of competent jurisdiction.
J. The form of the certificate of acknowledgment for a consent, a surrender, or any other document equivalent to a surrender, shall be substantially as follows:
STATE OF ….)
) SS.
COUNTY OF …)
I, …. (Name of judge or other person), …. (official title, name and location of court or status or position of other person), certify that …., personally known to me to be the same person whose name is subscribed to the foregoing (consent) (surrender), appeared before me this day in person and acknowledged that (she) (he) signed and delivered such (consent) (surrender) as (her) (his) free and voluntary act, for the specified purpose.
I have fully explained that by signing such (consent) (surrender) (she) (he) is irrevocably relinquishing all parental rights to such child or adult and (she) (he) has stated that such is (her) (his) intention and desire. (Add if Consent only) I am further satisfied that, before signing this Consent, …….. has read, or has had read to him or her, the Birth Parent Rights and Responsibilities-Private Form.
Dated (insert date).
Signature ……………
K. When the execution of a consent or a surrender is acknowledged before someone other than a judge, such other person shall have his or her signature on the certificate acknowledged before a notary public, in form substantially as follows:
STATE OF ….)
) SS.
COUNTY OF …)
I, a Notary Public, in and for the County of ……, in the State of ……, certify that …., personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me in person and acknowledged that (she) (he) signed such certificate as (her) (his) free and voluntary act and that the statements made in the certificate are true.
Dated (insert date).
There shall be attached a certificate of magistracy, or other comparable proof of office of the notary public satisfactory to the court, to a consent signed and acknowledged in another state.
L. A surrender or consent executed and acknowledged outside of this State, either in accordance with the law of this State or in accordance with the law of the place where executed, is valid.
M. Where a consent or a surrender is signed in a foreign country, the execution of such consent shall be acknowledged or affirmed in a manner conformable to the law and procedure of such country.
N. If the person signing a consent or surrender is in the military service of the United States, the execution of such consent or surrender may be acknowledged before a commissioned officer and the signature of such officer on such certificate shall be verified or acknowledged before a notary public or by such other procedure as is then in effect for such division or branch of the armed forces.
O. (1) The parent or parents of a child in whose interests a petition under Section 2-13 of the Juvenile Court Act of 1987 is pending may, with the approval of the designated representative of the Department of Children and Family Services (“Department” or “DCFS”), execute a consent to adoption by a specified person or persons:
(a) in whose physical custody the child has resided
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for at least 6 months; or
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the child who is the subject of this consent has resided for at least 6 months, and the child who is the subject of this consent is currently residing in this foster home; or
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of age has resided for at least 3 months.
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A consent under this subsection O shall be acknowledged by a parent pursuant to subsection H and subsection K of this Section.
(2) The final and irrevocable consent to adoption by a specified person or persons in a Department of Children and Family Services (DCFS) case shall be substantially as follows:
I, ……………………………….., the ……………… mother or father (circle one) of a male or female (circle one) child, state:
1. My child ………………………. (name of
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child) was born on ….. (insert date) at ……………….. Hospital in the City/Town of ………, in ……………. County, State of ……………
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…………. and State of …………..
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………………………., in care of ……………..
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My cell telephone number is………………………
My e-mail address is…………………………….
3. I, ………………………, am …. years old.
4. I enter my appearance in this action for my child
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to be adopted by the person or persons specified herein by me and waive service of summons on me in this action only.
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copy of the Birth Parent Rights and Responsibilities in Illinois for Final and Irrevocable Consents to Adoption by a Specified Person or Persons for DCFS Cases before signing this Consent and that I have had time to read this form or have it read to me and that I understand the rights and responsibilities described in this form. I understand that if I do not receive any of my rights as described in the form, it shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person or Persons.
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such child by ………. (names of current foster parent(s) or caregiver(s), hereinafter referred to as the “specified person or persons”) only.
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by signing this consent I irrevocably and permanently give up all my parental rights I have to my child.
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be adopted by the specified person or persons only and that I cannot under any circumstances after signing this document change my mind and revoke or cancel this consent.
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(a) the Department places my child with someone
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other than the specified person or persons; or
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specified person or persons to adopt my child; or
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to consent to my child’s adoption by the specified person or persons on the basis that the adoption is not in my child’s best interests.
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parental rights to my child, subject to any applicable court orders including those entered under Article II of the Juvenile Court Act of 1987, unless and until I sign a new consent or surrender or my parental rights are involuntarily terminated. I understand that if this consent is void, my child may be adopted by someone other than the specified person or persons only if I sign a new consent or surrender, or my parental rights are involuntarily terminated. I understand that if this consent is void, the Department will notify me within 30 days using the addresses and telephone numbers I provided in paragraph 2 of this form. I understand that if I receive such a notice, it is very important that I contact the Department immediately, and preferably within 30 days, to have input into the plan for my child’s future.
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my child is filed by someone other than the specified person or persons, the Department will notify me within 14 days after the Department becomes aware of the petition. The fact that someone other than the specified person or persons files a petition to adopt my child does not make this consent void.
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persons files a petition to adopt my child or if the consent is void under paragraph 9, the Department will send written notice to me using the mailing address and email address provided by me in paragraph 2 of this form. The Department will also contact me using the telephone numbers I provided in paragraph 2 of this form. It is very important that I let the Department know if any of my contact information changes. If I do not let the Department know if any of my contact information changes, I understand that I may not receive notification from the Department if this consent is void or if someone other than the specified person or persons files a petition to adopt my child. If any of my contact information changes, I should immediately notify:
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…………………………………………………;
Agency name, address, zip code, and telephone number:
…………………………………………………;
Supervisor’s name and telephone number:
…………………………………………………;
DCFS Advocacy Office for Children and Families:
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800-232-3798.
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paragraphs 8a and 8b, if applicable) do not impair the validity and finality of this consent under any circumstances.
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signing it as my free and voluntary act.
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………………………………………
Signature of parent
(3) If the parent consents to an adoption by 2 specified persons, then the form shall contain 2 additional paragraphs in substantially the following form:
8a. I understand that I cannot change my mind or
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revoke this consent or recover custody of my child on the basis that the specified persons divorce or are granted a dissolution of a civil union or that one of the specified persons has died.
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divorce or are granted a dissolution of a civil union before the petition to adopt my child is granted, this consent remains valid only for …………… (name only one specified person) to adopt my child.
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persons dies before the petition to adopt my child is granted, this consent remains valid for the surviving person to adopt my child.
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STATE OF …………..)
) SS.
COUNTY OF ………….)
I, ……………….. (Name of Judge or other person), ………………… (official title, name, and address), certify that …………., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent for Adoption by a Specified Person or Persons: DCFS Case, appeared before me this day in person and acknowledged that (she)(he) signed and delivered the consent as (her)(his) free and voluntary act, for the specified purpose.
I have fully explained that by signing this consent this parent is irrevocably and permanently relinquishing all parental rights to the child so that the child may be adopted by a specified person or persons, and this parent has stated that such is (her)(his) intention and desire. I have fully explained that this consent is void only if:
(a) the placement is disrupted and the child is moved
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to a different placement; or
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(c) the Department of Children and Family Services
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Guardianship Administrator refuses to consent to the child’s adoption by a specified person or persons on the basis that the adoption is not in the child’s best interests.
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………………………….
Signature
(5) If a consent to adoption by a specified person or persons is executed in this form, the following provisions shall apply. The consent shall be valid only for the specified person or persons to adopt the child. The consent shall be void if:
(a) the placement disrupts and the child is moved to
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another placement; or
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(c) the Department of Children and Family Services
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Guardianship Administrator refuses to consent to the child’s adoption by the specified person or persons on the basis that the adoption is not in the child’s best interests.
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(6) The Department of Children and Family Services is authorized to promulgate rules necessary to implement this subsection O.
(7) (Blank).
(8) The Department of Children and Family Services shall promulgate a rule and procedures regarding Consents to Adoption by a Specified Person or Persons in DCFS cases. The rule and procedures shall provide for the development of the Birth Parent Rights and Responsibilities Form for DCFS Cases.
(9) A consent to adoption by specified persons on this consent form shall have no effect on a court’s determination of custody or visitation under the Illinois Marriage and Dissolution of Marriage Act or the Illinois Religious Freedom Protection and Civil Union Act if the marriage or civil union of the specified persons is dissolved after the adoption is final.
P. If the person signing a consent is incarcerated or detained in a correctional facility, prison, jail, detention center, or other comparable institution, either in this State or any other jurisdiction, the execution of such consent may be acknowledged before social service personnel of such institution, or before a person designated by a court of competent jurisdiction.
Q. A consent may be acknowledged telephonically, via audiovisual connection, or other electronic means, provided that a court of competent jurisdiction has entered an order approving the execution of the consent in such manner and has designated an individual to be physically present with the parent executing such consent in order to verify the identity of the parent.
R. An agency whose representative is acknowledging a consent pursuant to this Section shall be a public child welfare agency or a child welfare agency that is authorized or licensed in the State or jurisdiction in which the consent is signed.
S. The form of waiver by a putative or legal father of a born or unborn child shall be substantially as follows:
I, ……………….., state under oath or affirm as follows:
1. That the biological mother …………… has
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named me as a possible biological or legal father of her minor child who was born, or is expected to be born on ……….., ……, in the City/Town of………, State of ………..
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…………. intends to or has placed the child for adoption.
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City/Town of……….., State of …………….
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date of birth is ……………, ………….
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….. am married to the biological mother.
….. am not married to the biological mother and
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have not been married to the biological mother within 300 days before the child’s birth or expected date of child’s birth.
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mother, but was married to the biological mother, within 300 days before the child’s birth or expected date of child’s birth.
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….. neither admit nor deny that I am the
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biological father of the child.
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child.
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parental rights, if any, without further notice to me of any proceeding for the adoption of the minor child, even if I have taken any action to establish parental rights or take any such action in the future including registering with any putative father registry.
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irrevocably and permanently give up all custody and other parental rights I may have to such child.
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IRREVOCABLE and that I am permanently barred from contesting any proceeding for the adoption of the child after I sign this Waiver.
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other pleadings in any proceeding to terminate parental rights, if any to this child, or any proceeding for adoption of this child.
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order of adoption for this child is not entered, then any parental rights or responsibilities that I may have remain intact.
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that I am signing it as my free and voluntary act.
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Dated: ………………., …………..
…………………………………….
Signature
I have been duly sworn and I state under oath that I have read and understood this Final and Irrevocable Waiver of Parental Rights of Putative or Legal Father. The facts contained in it are true and correct to the best of my knowledge. I have signed this document as my free and voluntary act in order to facilitate the adoption of the child.
…………………………
Signature
Signed and Sworn before me on
this ………… day
of ……….., 20….
……………….
Notary Public