Page 1 of 3 P-415 (8/17)(cs) AS 25.23.060-.070 ADOPTION CONSENT (PARENT/SPOUSE/GUARDIAN) Adoption Rule 9 IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the matter of the adoption of ) ) ) ) (child's name after adoption) ) ) By , ) CASE NO. Petitioner. ) ) ADOPTION CONSENT (PARENT/SPOUSE/GUARDIAN) 1. Name of individual signing consent to adoption: 2. 3. Relationship to child: 4. I understand that prior to signing this consent I have the right to consult with an attorney of my choice, at my expense. I also understand that if I do not sign the consent, but the person(s) seeking to adopt the child proceeds with filing the adoption I am married to the petitioner and I am retaining my rights to care, custody, and control of the child. I understand that by signing this consent, I am giving up all my rights to the care, custody and control of the child, and that I am giving up these rights permanently. I will also be permanently relieved of all responsibility for the child after the decree of adoption is signed. Except as stated in paragraph 7 below concerning inheritance and visitation privileges, I will no longer have any legal This section is not applicable to me because I am married to the petitioner so I am retaining my legal rights to care, custody, and control of the child. I do not want to keep any visitation privileges after the adoption is granted. I request that the court grant me my relative visitation privileges with the child at the discretion of the adoptive parent(s), according to the best interests of the child. A Page 2 of 3 P-415 (8/17)(cs) AS 25.23.060-.070 ADOPTION CONSENT (PARENT/SPOUSE/GUARDIAN) Adoption Rule 9 I request that the court grant me my relative the following visitation privileges with the child: (Describe visitation agreement, including times, places, who pays for transportation, etc. Attach any visitation agreement if applicable.) 8.The child is is not a member of an Indian tribe; or eligible for suchmembership and I, or the other biological parent, am a member of an Indian tribe.9.I understand I have a limited right to withdraw my consent. I understand that myconsent cannot be withdrawn after the judge signs the decree of adoption. However,before the adoption decree is signed, I can withdraw my consent as follows:a.For a Non-Indian Child:Within 10 days after I sign this form, I can deliver written notice of withdrawal tothe court at the address in paragraph 10 or to the person who obtained myconsent. This written notice must be delivered or postmarked by the tenth day,and I must keep a copy of that notice of withdrawal and record the date it wasdelivered or postmarked.After the above 10-day period, if the adoption decree has not been signed, I canfile a request to withdraw with the court, which the court may or may not grant.My request will be granted only if the court finds that it is in the best interests ofthe child after both the person seeking to adopt and I are given notice and anopportunity to be heard.b.For an Indian ChildAt any time before the signing of the decree of adoption, I can deliver writtennotice of withdrawal to the court at the address in paragraph 10 or to the personwho obtained my consent. This written notice must be delivered or postmarkedby the last day of this time period, and I must keep a copy of that notice andrecord the date it was delivered or postmarked.10.I understand that the adoption petition will be filed in the Superior Court at:Court Address: Court Telephone Number: [NOTE: You can find the location and court telephone number here: http://www.courts. alaska.gov/courtdir/index.htm] 11.I am am not a minor. My date of birth is . 12.I have received a copy of this consent (or will receive one after it is signed).13.I do do not want to receive notice of the date and time of the adoption hearing. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 P-415 (8/17)(cs) AS 25.23.060-.070 ADOPTION CONSENT (PARENT/SPOUSE/GUARDIAN) Adoption Rule 9 I state on oath or affirm that I have read this consent form and believe all statements made in it are true. I am signing this consent freely and voluntarily. Note: This consent must be signed in a hearing in the presence of a judge when the consenting person is the parent of an Indian child or the consenting person is a minor. Date Signature of Person Giving Consent Print Name Mailing Address City State Zip Daytime Phone Email Address ACKNOWLEDGEMENT & OATH On , personally appeared (date) (name) before me in , Alaska, signed the above consent to adoption, certified under oath or affirmation that he/she has read it and believes its contents to be true, and acknowledged that he/she signed the consent freely and voluntarily for the purposes stated therein. (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com