Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 1 of 5en-US Person or Persons; Non-DCFS Case þ (01/23/19) CCCO N203 A en-USIN THE CIRCUIT COURT OF COOK COUNTY, ILLINOISen-USCOUNTY DEPARTMENT - COUNTY DIVISIONen-USFINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR en-USIN THE MATTER OF THE ADOPTION OF en-USA Minor Case No. þ I, þ en-US , (relationship, þ Mother þ þ Father þ Other þ en-USen-US) of, (gender, þ Male þ þ Female) child, state; 1. That the child was born on þ þ at þ þ AM þ þ PM en-USin the City/Town of þ and State of þ en-US . 2. That I reside at þ en-US , County of þ en-US and State of en-US ; my email address (if I have one) , is þ en-US ; my cell phone number where I can receive text messages (if I have one) is þ ; my land line phone number (if I have one) is þ en-US ; and any other contact information is en-US . 3. That I am of the age of þ en-US years. 4. en-USThat I hereby enter my appearance in this proceeding and waive service of summons on me. 5. en-USThat I hereby acknowledge that I have been provided a copy of the Birth Parents Rights and Responsibilitiesen-USPrivate Form before signing this Consent and that I have had time to read, or have had read to me, this Formen-USand that I understand the Rights and Responsibilities described in this Form. I understand that if I do noten-USreceive any of the rights as described in said Form, it shall not constitute a basis to revoke this Final anden-US6. en-USThat I do hereby consent and agree to the adoption of such child by þ en-USen-USen-USDorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 2 of 5 7. en-USThat I wish to and understand that upon signing this consent I do irrevocably and permanently give up allen-UScustody and other parental rights I have to such child if such child is adopted by þ en-USen-UStransfer all of my rights to the custody, care and control of such child to þ en-US 8. That I understand such child will be adopted by þ en-USen-USen-USmind and revoke or cancel this consent or obtain or recover custody or any other rights over such child if þ en-USen-USen-USadoption of such child. 9. en-USen-USen-USadoption petition is dismissed with prejudice or the adoption proceeding is otherwise concluded without anen-USen-USsent written notice of such circumstances at the mailing address, at the email address, through a text message toen-USmy cell phone number, and to any other contact information I have provided in paragraph 2 within 5 businessen-USdays of this occurrence. I understand that the notice will be directed to me using the contact information Ien-UShave provided in this consent. I understand that I will have 15 business days from the date that the writtenen-USen-USCourt to declare this consent voidable and return the child to me. I further understand that the Court will makeen-USen-USbusiness days of the date the notice was sent, then I expressly waive any other notice or service of process inen-USany legal proceeding regarding the child, including a legal proceeding for someone other than þ en-USen-USen-USof notice as proof of the date sent. en-USen-USConsent under any circumstance other than those described in paragraph 9267of this Consent. 11. en-USThat I understand that I have a remaining duty and obligation to keep þ en-US (inserten-USen-USen-UStermination of my parental rights and the child being placed for adoption in another home. 12. en-USThat I do expressly waive any other notice or service of process in any of the legal proceedings for theen-US 13. en-USThat I have read and understand the above and I am signing it as my free and voluntary act.en-US Person or Persons; Non-DCFS Case þ (01/23/19) CCCO N203 B Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 3 of 5 14. en-USen-USen-US Person or Persons; Non-DCFS Case þ (01/23/19) CCCO N203 C þ en-US þ at þ þ þ AM þ þ PM en-USSignature of Parent en-USAddress of Parent en-USPhone number(s) of parent en-USPersonal email(s) of parenten-USSTATE OF ILLINOISen-USCOUNTY OF COOK en-USen-USACKNOWLEDGMENT I, þ en-US (name of Judge or other person),en-US certify that þ en-US , personally known to me to be the same en-USen-USen-US before signing this Consent, þ en-US has read, or has had read to him or her, en-USen-USen-USJudgeDorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 4 of 5en-USAs a birth parent in the State of Illinois, you have the right: 1. en-USTo have your own attorney represent you. The prospective adoptive parents may agree to pay for the cost ofen-US 2. en-USTo be treated with dignity and respect at all times and to make decisions free from coercion and pressure. 3. en-USen-USen-USen-USadoptive parents may agree to pay for the cost of counseling in a manner consistent with Illinois law, but theyen-US 4. en-USTo ask to be involved in choosing your child222s prospective adoptive parents and to ask to meet them. 5. en-USen-USwith them. 6. en-USen-USto see your child if you are not the custodial parent. 7. en-USen-USthat any promises regarding contact with your child or receipt of information about the child after signing aen-US 8. en-USTo receive copies of all documents that you sign and have those documents provided to you in your preferreden-USlanguage. 9. en-USen-USor court order, and to voluntarily share your medical, background, and identifying information, includingen-USen-USRegistry and Medical Information Exchange or through completing the Birth Parent Preference Form. Pleaseen-US en-USen-USand/or exchange information between adoptees, adoptive parents and birth parents, and other biological familyen-USen-US 11. en-USTo work with an adoption agency or attorney of your choice, or change said agency or attorney, provided youen-USpromptly inform all of the parties currently involved. 12. en-USen-USthe attorney for your child222s prospective adaptive parents. 13. en-USen-USBIRTH PARENT RIGHTS AND RESPONSIBILITIES - PRIVATE FORMen-USTHIS FORM DOES NOT CONSTITUTE LEGAL ADVICE. LEGAL ADVICE IS DEPENDENT en-USON THE SPECIFIC CIRCUMSTANCES OF EACH SITUATION AND JURISDICTION. THE en-USINFORMATION IN THIS FORM CANNOT REPLACE THE ADVICE OF AN ATTORNEY en-USLICENSED IN YOUR STATE.en-US Person or Persons; Non-DCFS Case þ (01/23/19) CCCO N203 D Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 5 of 5 14. en-USen-USfrom the prospective adaptive parents.en-USen-USConsent, or Unborn Consent.en-USAs a Birth Parent in the State of Illinois, you have the responsibility: 1. en-USTo carefully consider your reasons for choosing adoption. 2. en-USen-USchild when known, with the understanding that a birth mother has a right to decline to identify the birth father. 3. en-USen-US 4. en-USen-USthan one source or if you are not pregnant, as doing so is a crime. 5. en-USTo voluntarily provide all known medical, background, and family information about yourself and youren-USimmediate family to your child222s prospective adoptive parents or their attorney. For the health of your child, youen-US þ en-US . 6. en-USI have read and received a copy of this form. Signature of Biological Parent þ Date en-USPrinted Name of Biological Parent Signature of Biological Parent þ Date en-USPrinted Name of Biological Parenten-US Person or Persons; Non-DCFS Case þ (01/23/19) CCCO N203 E