Form 140 (Rev. 10/12) The Family Court of the State of Delaware In and For New Castle Kent Sussex County CONSENT TO TERMINATE AND TRANSFER PARENTAL RIGHTS Petitioner Name Street Address (including Apt) P.O. Box Number City/State/Zip Code D.O.B. Attorney Name v. Respondent Name Street Address (including Apt) P.O. Box Number City/State/Zip Code D.O.B. Attorney Name File Number Petition Number 1. I , , , , am the Mother Father of the following children: Born on Born on Born on Born on 2. I consent to the termination and transfer of my parental rights in my child(ren) named in paragraph 1 above for the purpose of adoption to: The individual(s) selected by the Dept. of Services for Children, Youth and Their Families or an approved adoption agency; namely: (Chosen Adopted Parents: 3. 4. 5. I understand the importance of my decision and fully realize the effects of the termination of my parental rights in this child (these children). I understand that by terminating my parental rights, all of my rights and obligations to this child (these children) will be extinguished, except for any arrearages of child support. I understand that after this consent is signed by me, this consent is final and may not be revoked by me for any reason except: (a) within fourteen days of executing this consent, I notify in writing the agency or the individual to whom the parental rights have been transferred that I revoke my consent; (b) I comply with the following instruction for revocation (c) the agency or individual that accepted the consent and I agree to its revocation. 6. I also understand that the Court may set aside my consent if I establish: (a) By clear and convincing evidence, before a decree of adoption is issued, that my consent was obtained by fraud or duress; or (b) By a preponderance of the evidence, that a condition permitting revocation, as expressly provided for in this consent, as set forth in Paragraph 5(b) above, has occurred. I understand that this consent may be revoked if a court of competent jurisdiction decides not to terminate the other parent's rights to this child (these children). American LegalNet, Inc. www.FormsWorkFlow.com 7. 1 of 3 Form 140 (Rev. 10/12) 8. 9. I have read and/or have had read to me the seven statements set forth on an attachment to this form and fully understand and agree with each statement. I understand that I have a right to file a written notarized statement with the Department of Health and Social Services, Division of Vital Statistics, denying the release of any identifying information. I am aware that, notwithstanding any other provision in the Delaware Code to the contrary, an adoptee 21 years of age or older may obtain a copy of his or her original record of birth from the State Registrar, even if that record has been impounded, unless the birth parent has, within the most recent three-year period, filed a written notarized statement with the Department of Health and Social Services, Division of Vital Statistics, denying the release of any identifying information. 10. I know and understand that I have the right to be served with a copy of the petition for termination of my parental rights and to attend a hearing on my important decision to terminate my parental rights in my child(ren). I understand that the Family Court may conduct a hearing on this matter, which I have a right to attend. I waive my rights to the following: my right to service of process; my right to notice of such a hearing; and my right to attend the hearing. 11. I would like to receive a copy of the final order of the Court Yes No 12. The attorney who is representing me in regards to this consent is ,Esq. Any questions I have about this consent were answered by the attorney. If I do not have an attorney, I understand that if I cannot afford an attorney, an attorney may be appointed to represent me at no cost. I knowingly and voluntarily waive any right I might have to an attorney by checking this box: 13. I understand that I will receive a copy of my signed consent. 14. I have signed this consent voluntarily and of my own free will. I have not been promised nor have I received any money or anything else of value in exchange for this consent. at Date and Time Signed (AM/PM) Signature of Consenting Parent Printed Name of Consenting Parent Location of Signing Mailing Address of Consenting Parent Street Address P.O. Box Number City/State/Zip Code 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 140 (Rev. 10/12) TERMINATION OF PARENTAL RIGHTS CONSENT PARTY STATEMENT I, who was born on 1. 2. 3. 4. 5. , the mother father of do state that I: 6. 7. Believe that placement of my child for adoption by , would be In the child's best interest. Know that the decision to terminate my parental rights is an important one. Know and understand that when my parental rights in my child are terminated, I will no longer be the legal parent of my child. Know and understand that when I terminate my parental rights in my child that I give up all rights. Know and understand that when I terminate my parental rights in my child and child is adopted, the child becomes the child of and , and as a result the child's name may be changed. Know and understand that when I terminate my parental rights in my child, my child loses the right to inherit from me and I lose the right to inherit from him/her. This shall not in any way limit my right to provide for the disposition of my estate by will. Know and understand that I have the right to be represented by an attorney in this matter, and may be entitled to have the Court appoint an attorney to represent me for free. Consenting Party Date CONFIRMATION STATEMENT I, the undersigned, hereby certify the following: 1. I am a person authorized to take consents to terminate parental rights under 13 Del. C. � 1106(c) because I am A judge of a court of record; An individual designated by a judge to take consents; An employee designated by an agency to take consents; A lawyer other than a lawyer who is representing an adoptive parent or the agency to which parental rights will be transferred; A commissioned officer on active duty in the military service of the United States, if the individual executing the consent is in the military service; or An officer of the Foreign Service or a consular officer of the United States in another country, if the individual executing the consent is in that country. 2. I have explained the contents and consequences of the consent t