Print Form Consent to Adoption of Unborn Child (To only be executed by a male) Clear Form (Rev. 8/27/07) CCCO 0033 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - COUNTY DIVISION CONSENT TO ADOPTION OF UNBORN CHILD (2723) (To only be executed by a male) I, 1. _____________________________________________, state: That I am the father of a child expected to be born on or about ___________________________, ________ to _________________________________________________, 2. ________________________________________________________ City/Town or Village _________________________ County of ___________________, and State of ___________________. of (Name of mother). That I reside at 3. That I am of the age of _____________ years. 4. That I hereby enter my appearance in such adoption proceeding and waive service of summons on me. 5. That I do hereby consent and agree to the adoption of such child, and that I have not previously executed a consent or surrender with respect to such child. 6. That I wish to and do understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child, except that I have the right to revoke this consent by giving written notice of my revocation not later than 72 hours after the birth of the child. 7. That I understand such child will be placed for adoption and that, except as hereinabove provided, I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over such child. That I have read and understand the above and I am signing it as my free and voluntary act. Dated: ____________________________, __________. ____________________________________ Signature Insert appropriate Certificate of Acknowledgement from statute or as found in exhibit 5 when executed in presence of a Judge. CERTIFICATE OF ACKNOWLEDGEMENT ______________________________________________________, (Name of judge or other person), _________________________________________(official title, name and location of court or status or position of other person), certify that _____________________________________, personally known to be the same person I, whose name is subscribed to the foregoing consent appeared before me this day in person and acknowledged that he signed and delivered such consent as his free and voluntary act, for the specified purpose. I have fully explained that by signing such consent he is irrevocably relinquishing all parental rights to such child or adult and he has stated that such is his intention and desire. Dated: ______________________________, __________. ____________________________________ Signature DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS