IN THE DISTRICT COURT OF ________________________ COUNTY STATE OF OKLAHOMA JUVENILE DIVISION IN THE MATTER OF: DOB: DOB: DOB: DOB: DOB: DOB: ) ) JD) ) Date: ) Judge: ) ) ___________ _ Alleged Deprived Child(ren). REQUEST TO CONSENT TO THE TERMINATION OF PARENTAL RIGHTS AND COURT'S FINDINGS AND ORDER TERMINATING THE NATURAL PARENT'S RIGHTS COMES NOW Parent of the above named child(ren), by and through his/her counsel, , and pursuant to Title 10A O.S. 1-4-904 represents and shows to the Court as follows: (parent initials each item) _____ 1. Parent states Parent was born on the day of , ________, and Parent is years old. Parent states that he/she is the parent of each child as follows: Child's Name Mother's Name Father's Name _____ 2. Parent of the child(ren), herein, hereby voluntarily and irrevocably consents to the termination of his/her parental rights. _____ 3. He/She further states, that as the child(ren)'s parent, he/she believes it to be in their best interest that he/she consent to termination of her parental rights. _____ 4. Parent further states that he/she understands that this consent to terminate his/her parental rights is final and cannot be revoked or set aside absent a finding that it is in the best interests of the child(ren). _____ 5. Parent further states that he/she understands that the execution of this document will terminate his/her parental rights; that the termination of parental rights terminates the parent-child relationship, including the parent's right to the custody of the child(ren) and his/her right to visit the child(ren), his/her right to Request to Consent and Order Terminating Parent's Rights OK-J-UO- 0007 Version1.1.16.2 Page 1 of 4 OCIS Docket Code: OTPR American LegalNet, Inc. www.FormsWorkFlow.com control the child(ren)'s training and education, the necessity for the parent to consent to the adoption of the child(ren) and parent's right to the earnings for the child(ren), and the parent's right to inherit from or through the child(ren). Provided that the child(ren) continues to have the right to inherit from the parent. _____ 6. Parent further states that he/she understands that the execution of this consent does not terminate the duty of support of the above named child(ren) unless or until an adoption of the child(ren) is completed. _____ 7. Parent further states that he/she is is not, a member of an Indian tribe and that, to his/her knowledge, the child(ren) are are not members of an Indian tribe or that the child(ren) are are not eligible for membership to an Indian tribe. _____ 8. Parent further states that he/she has not been promised any money or anything of value in exchange for his/her consent to terminate his/her parental rights, nor has been threatened or coerced in any manner and that this consent is freely, knowingly and voluntarily entered into. _____ 9. He/She further acknowledges that he/she understands that this consent to termination is unconditional. _____ 10. Parent further states he/she understands that before the state could terminate his/her parental rights, he/she would be entitled to a trial by jury and the state would have the burden of proving a statutory basis for terminating his/her rights; that he/she would be entitled to an attorney, and if he/she could not afford one, the Court would appoint an attorney to represent him/her. IN WITNESS WHEREOF, I Court on this day of ________________________________________________ Parent ________________________________________________ ________________________________________________ (Address) , 20 have subscribed my name in open . ______________________________________________ Attorney for Parent Request to Consent and Order Terminating Parent's Rights OK-J-UO- 0007 Version1.1.16.2 Page 2 of 4 OCIS Docket Code: OTPR American LegalNet, Inc. www.FormsWorkFlow.com FINDINGS OF FACT AND ORDER TERMINATING PARENTAL RIGHTS THE COURT, having been fully advised of the premises herein hereby FINDS as follows: 1. Parent in the above-entitled cause appeared before the undersigned Judge on this date and having been placed under oath has acknowledged his/her intent to consent to the termination of his/her parental rights. 2. The terms and consequences of the Parent's Consent to Termination of Parental Rights were fully explained in English or interpreted into a language that the Parent understood; 3. Parent has acknowledged that he/she fully understood the terms and consequences of the Consent to Termination of Parental Rights; 4. Parent has executed the Request to Consent to the Termination of Parental Rights before the Court; 5. Parent's consent to termination of his/her parental rights was knowingly and voluntarily made. 6. Termination of the Parent's parental rights is in the best interests of the child(ren). IT IS THEREFORE ORDERED AND DECREED by this Court that the parental rights of to the child(ren) are hereby terminated. DATED this _______ day of _____________________________, 20______. ________________________________________________ JUDGE OF THE DISTRICT COURT Request to Consent and Order Terminating Parent's Rights OK-J-UO- 0007 Version1.1.16.2 Page 3 of 4 OCIS Docket Code: OTPR American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF DELIVERY/ MAILING The undersigned does hereby certify that on the day of , 20 , true and correct copies of the above and foregoing order were placed in the U.S. Mails with proper postage prepaid thereon to the address of court record: Attorney: Attorney: Attorney: Attorney: Attorney: Attorney: Mother Mother Father Father Father Father State Tribe(s) Legal Guardian for for for for for for Child: Child: Child: Child: Child: Child: Attorney: Attorney: Attorney: Attorney: Attorney: Attorney: DHS GAL/CASA Other Judge of the District Court Court Clerk of BY: Court Clerk/ Deputy /Bailiff County OR hand-delivered to the following: for for for for for for Child: Child: Child: Child: Child: Child: Attorney: Attorney: Attorney: Attorney: Attorney: Attorney: DHS GAL/CASA Other Judge of the District Court Court Clerk of BY: Court Clerk/ Deputy /Bailiff County Attorney: Attorney: Attorney: Attorney: Attorney: Attorney: Mother Mother Father Father Father Father State Tribe(s) Legal Guardian Request to Consent and Order Terminating Parent's Rights OK-J-UO- 0007 Version1.1.16.2 Page 4 of 4 OCIS Docket Code: OTPR American LegalNet, Inc. www.FormsWorkFlow.com