Form 124P Rev. 09/15 The Family Court of the State of Delaware In and For New Castle Kent Sussex County CONSENT ORDER ­ PERMANENT GUARDIANSHIP Petitioner Name Street Address P.O. Box Number City/State/Zip Code Phone Number Relation to Child(ren) D.O.B. Respondent Name Street Address P.O. Box Number City/State/Zip Code Phone Number Relation to Child(ren) D.O.B. File Number Petition Number Attorney Name Attorney Name Interpreter needed? Language Yes No Interpreter needed? Language Yes No Petitioner (if any) Name Street Address P.O. Box Number City/State/Zip Code Phone Number D.O.B. Respondent (if any) Name Street Address P.O. Box Number City/State/Zip Code Phone Number D.O.B. Relation to Child(ren) Relation to Child(ren) Attorney Name Attorney Name Interpreter needed? Language Yes No Interpreter needed? Language Yes No Guardian Ad Litem (if any) Name Street Address P.O. Box Number City/State/Zip Code Phone Number Attorney for Guardian Ad Litem Interpreter needed? Language Yes No 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 124P Rev. 09/15 IN THE INTEREST OF the following child: Name , Date of Birth The parties in the above entitled cause agree upon the following arrangement and do consent to the entry of an Order providing for same: PERMANENT GUARDIANSHIP AWARDED TO: i Relationship to Child: P.O. Box Number City/State/Zip Code Street Address For Respondent: I understand the importance of my decision and fully realize the effects of granting permanent guardianship of my child to the above-named individuals; I understand that I retain the following rights: a. b. c. d. The right to visitation, contact and information as ordered by the court; The right to inheritance by and from the child; The right to consent to termination of parental rights and/or adoption of the child; AND The right to seek modification of the visitation, contact and information portions of the permanent guardianship order. I understand that after this consent is signed by me and confirmed, I may not petition the Court to modify or terminate the Permanent Guardianship. I understand that I may still have the primary responsibility to support my child financially; I know and understand that I have the right to be served with a copy of the petition for permanent guardianship, and have a hearing on that petition. I understand that the Family Court may conduct a hearing on this matter. I hereby waive my right to service and any notice of such hearing by checking the following box ; I know that I will receive notice of the final order of the Court only if I check the following box I have received a copy of my signed consent; and I have signed this consent voluntarily and of my own free will. I have neither been promised nor received any money or anything else of value in exchange for this consent. Respondent(s) shall have visitation as follows: ; 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 124P Rev. 09/15 BE IT REMEMBERED, that on this date, , , who, being duly sworn by me according to the law personally appeared before me, a Notary Public for the State and County declared above, did depose and say: We, the undersigned, hereby agree upon the following permanent guardianship agreement for the above-named child. We signed this consent agreement voluntarily and of our own free will. THE RESPONDENTS ACKNOWLEDGE THAT EACH WAS ADVISED THAT IF HE/SHE IS INDIGENT AND WISH TO HAVE COURT APPOINTED COUNSEL REPRESENT HIM/HER IN THIS ACTION, COUNSEL WOULD BE APPOINTED FOR HIM/HER IN THIS ACTION. HE/SHE FREELY AND VOLUNTARILY WAIVES HIS/HER RIGHT TO COUNSEL. This agreement of the parties is subject to review of the parties' criminal histories by a hearing officer before entry as an order of the court. The parties hereby waive their right to a Review of a Commissioner's Order as this Order is entered pursuant to their voluntary agreement Child (if over 14 years of age) Petitioner 2nd Petitioner (if any) Respondent SWORN TO AND SUBSCRIBED before me this date, 2nd Respondent (if any) Notary Public/Clerk of Court SO ORDERED this Day of , . Judge/Commissioner 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com