IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the matter of the adoption of (child's name after adoption) , A Minor Child, Petitioner. My name is I am years old. , ) ) ) ) ) ) ) ) ) DOB: By CASE NO. ADOPTION CONSENT (CHILD 10 OR OLDER) . 1. 2. 3. 4. 5. (child's current full name) I understand that before I sign this consent I have the right to consult with an attorney of my choice, at my expense, or I may ask the court to appoint an attorney for me. I consent to be adopted by the petitioner named above. I understand if this adoption is granted it will terminate parental rights between me and my biological mother father. It will also create the legal relationship of parent and child between me and the petitioner named above. Visitation. I understand that no visitation privileges will be retained after adoption. may retain visitation with me after adoption. 6. 7. 8. 9. I am am not a member of an Indian tribe; or eligible for tribal membership and either of my biological parents is a member of an Indian tribe. I understand I have a limited right to withdraw my consent. I understand that my consent cannot be withdrawn after the judge signs the decree of adoption. I understand that the adoption petition has been or will be filed in the Superior Court at: Court Address: Court Telephone Number: 10. 11. I have received a copy of this consent (or will receive one after it is signed). I am not married. Date married. My spouse is: Child's Signature (Signed in the presence of the court) AS 25.23.060-.070, .130 AS 25.24.310 American LegalNet, Inc. Adoption Rule 9 www.FormsWorkFlow.com Page 1 of 2 P-420 (12/16)(cs) ADOPTION CONSENT (CHILD 10 OR OLDER) CERTIFICATION BY COURT I certify that the terms and consequences of the above consent to adoption were explained in detail to the minor child in a language that the child understood and that the child understood these terms and consequences and voluntarily signed the consent. Date Superior Court Judge/Master Type or Print Name Page 2 of 2 P-420 (12/16)(cs) ADOPTION CONSENT (CHILD 10 OR OLDER) AS 25.23.060-.070, .130 AS 25.24.310 American LegalNet, Inc. Adoption Rule 9 www.FormsWorkFlow.com