FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I RELEASE OF CHILD FOR ADOPTION CASE NUMBER FC-A NO. Full Legal Name of Mother: Date Mother222s Child Expected to be born: Full Legal Name of Alleged Natural Father: I, the above-named alleged natural father hereby states that I have been advised that the mother above-identified has named me as the natural father of her expected child. [ ] I hereby acknowledge that I am or may be said child222s father. I consent to the adoption of aid child by adoptive parents to be selected as directed by and waive further notice of any condition of or action respect to said child. In order to facilitate the care and well-being of said expected child. I release any parental interest and consent to the termination of any parental rights I may be deemed or believed to have in said child. [ ] I am without sufficient information to acknowledge or deny that I am said expected child222s father. However, in order to facilitate the care and well-being of said expected child, I release any parental interest and consent to the termination of any parental rights I may be deemed or believed to have in said child and I consent to the child222s adoption by parents to be selected as directed by . [ ] I hereby deny that I am the natural father of said (expected) child. However, in order to facilitate the care and well-being of said expected child, I release any parental interest and consent to the termination of any parental rights I may be deemed or believed to have in said child and I consent to the child222s adoption by parents to be selected as directed by . I do not wish to receive any further contact or notification of any action in respect to said child. If after the child reaches the age of majority, said child wishes to locate me, I do; do not; am undecided in respect to whether I wish to have my identity disclosed to said child. In any event, I understand that it is my responsibility to advise the Court as to my whereabouts if I wish such disclosure to be made to this child upon his or her reaching adulthood and initiating such a request. 08/07/01 PAGE 1 OF 2 PAGES RELEASE OF CHILD FOR ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com FAMILY COURT FIRST CIRCUIT STATE OF HAWAI221I RELEASE OF CHILD FOR ADOPTION CONFIDENTIALITY PURSUANT TO HRS 247578-15: 1. I have been advised of the requirements of Section 578-15 of the Hawai221i Revised Statutes regarding confidentiality of the court's adoption file. 2. When my child becomes 18 years old, my child or the adoptive parents can request, in writing, to see the court's file regarding this adoption. 3. If I do not want the Family Court to reveal my identity to my child or the adoptive parents, I must file an affidavit requesting confidentiality with the Family Court (on this island that the adoption occurred) within ninety (90) calendar days before my child's 18th birthday. This affidavit is good for ten (10) years. 4. After that, I can file an affidavit every ten (10) years or I can file an affidavit to keep my identity confidential for the rest of my life. 5. All affidavits must be filed within ninety (90) days prior to the expiration of the previous affidavit. 6. After my child reaches 18 years old, I can request to see the court's adoption file, too, but my child has the same rights as I do the keep the file confidential. 7. My decision to keep my information confidential or not applies to only me and does not apply to the other natural parent. 8. I can agree to open up the adoption file at any time and my child can to after turning 18 years old. 9. It will be my responsibility to keep the Family Court informed of my current address if I want disclosure to be made. 10. The Family Court has no responsibility to notify the child, adoptive parent(s) or the natural parent(s) of any deadlines or expiration dates. SIGNATURE On this day, before me personally appeared , to me known to be person named in and who executed the foregoing document and acknowledged that said document was read and is understood by said person and was executed as the free act and deed of said person. State of Hawai221i, County of Honolulu: Date Signature: NotaryPublic, State of Hawaii Printed Name of Notary Public: Commission Expires: 08/07/01 PAGE 2 OF 2 PAGES RELEASE OF CHILD FOR ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com