FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I Child's Legal Name CONSENT BY CHILD (AGE 10 OR OVER) TO ADOPTION Child's Birthdate CASE NUMBER FC-A No. Child's Birth Place Name of Proposed Adoptive Parent(s) Relationship to Child I, the above-named child being (age) years old, do consent to my adoption by the above-named person(s) who I believe will be a good parent(s) and able and willing to give me a proper home and education. I understand that once I am adopted I shall no longer be the legal child of my present legal [ ] mother [ ] father [ ] parents, but will become the child of the above-named person(s) as if I had been born to him, her, or them. _ (In Stepparent Adoptions) However, I understand that even after the adoption is granted, I shall still be the child of my [ ] father [ ] mother, who is now married to the person wanting to adopt me. Because I believe the proposed adoption is in my best interest, I request that the Court grant this adoption and change my name to . DATE SIGNATURE OF CHILD SOCIAL SECURITY NUMBER DATE SIGNATURE OF WITNESS PRINT NAME OF WITNESS Ho`okele/FC Adm 1/7/16 CONSENT OF CHILD (AGE 10 OR OVER) TO ADOPTION In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions regarding forms or procedures. Reprographics (2/2016) 1F-P-1039 American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified