07/2018 KSJC 1 PREBIRTH CONSENT TO ADOPTION OF MINOR CHILD NOTICE TO POSSIBLE FATHER: This is an important legal document and by signing it you are permanently giving up all custody and other parental rights to the child named in this consent, so as to permit the child's adoption. You are to receive a copy of this document. I, (man222s name) state: 1. I have been informed that (name of pregnant woman) is pregnant with a child expected to be born on (date). 2. I (am) (may be) the father of the child. [I am signing this consent without admitting that I am the father of the child and without admitting any financial responsibility for the child, but solely because I have been identified as a possible father of the child.] 3. I reside at, county of and state of . [My social security number is XX-XXXX- .] 4. I am years of age and was born in (year) . 5. As required by law, I have been advised by independent legal counsel of the consequences of signing this consent, and counsel was present when I signed it. 6. I consent and agree to the adoption of the child [by ] [and I do not require disclosure of the name or other identification of the adopting parent or parents]. 7. I wish to and understand that by signing this consent I do permanently give up all custody and other parental rights I have to the child. I understand that, if I am the child222s father, this consent does not relieve me of any parental obligations, including support, until the adoption is finalized. 8. [To the best of my knowledge, neither I nor the pregnant woman are members of or eligible for membership in an Indian tribe recognized by federal law.] [I am a member of the tribe, (address) .] [The pregnant woman is a member of the tribe, (address) .] 9. [I freely and voluntarily enter my appearance in any proceeding instituted in any court of competent jurisdiction for the adoption of the child. I choose (to receive) (not to receive) notice of the time, date and location of the final hearing. If I have chosen to receive notice, I request that the notice of final hearing be sent to me at the following address by regular mail at least 10 days prior to the hearing: .] American LegalNet, Inc. www.FormsWorkFlow.com 07/2018 KSJC 2 10. I am of sound mind and under no undue restraint or duress. I have read and understand the above and I am signing it as my free and voluntary act. Dated , at .m. (signature of possible father) [Must be acknowledged either before a judge or a notary public. Choose the appropriate acknowledgment from the two options below.] ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT STATE OF ) ) COUNTY OF ) I, , Judge of (name and location of court) , certify that , known to me to be the same person whose name is signed on this consent, appeared before me this day in person and acknowledged that he signed this consent as his free and voluntary act, for the specified purpose. I have fully explained that by signing this consent he is permanently giving up all parental rights to the child and he has stated that such is his intention and desire. Dated , at .m. (signature of judge) ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER STATE OF ) ) COUNTY OF ) This consent was acknowledged before me on ( date ) at ( time ) by ( name of person ). (signature of Notarial Officer) (SEAL, if any) title (and rank) [My Appointment Expires: ] American LegalNet, Inc. www.FormsWorkFlow.com 07/2018 KSJC 3 CERTIFICATE OF ATTORNEY FOR POSSIBLE FATHER CONSENTING PREBIRTH I am a licensed attorney representing . I have fully explained that by signing this consent is permanently giving up all parental rights to the child and he has stated that such is his intention and desire. I was present at the execution of this consent. Dated (signature of attorney) Authority: K.S.A. 59-2143 American LegalNet, Inc. www.FormsWorkFlow.com