Print Form Final and Irrevocable Waiver of Parental Rights of Putative or Legal Father Clear Form (07/03/13) CCCO 0204 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION FINAL AND IRREVOCABLE WAIVER OF PARENTAL RIGHTS OF PUTATIVE OR LEGAL FATHER I, _________________________________________________________________ , state under oath or affirm as follows: 1. That the biological mother, ______________________________________________________________ , has named me as a possible biological or legal father of her minor child who was born, or is expected to be born on _______________________, _______, in the City/Town of ________________________________________, State of Illinois. 2. That I understand that the biological mother, ____________________________________________________, intends to or has placed the child for adoption. 3. That I reside at ___________________________________________________________________________, in the City/Town of ____________________________________________________ State of ___________. 4. That I am __________ years of age and my date of birth is _______________________, _______. 5. That I (Select one): am married to the biological mother. am not married to the biological mother and have not been married to the biological mother within 300 days before the child's birth or expected date of birth. am not currently married to the biological mother, but was married to the biological mother, within 300 days before the child's birth or expected date of child's birth. 6. That I (Select one): deny that I am the biological father of the child. admit that I am the biological father of the child. neither admit nor deny that I am the biological father of the child. 7. That I hereby agree to the termination of my parental rights, if any, without further notice to me of any procedding for the adoption of the minor child, even if I have taken any action to establish parental rights or take any such action in the future including registering with any putative father registry. 8. That I understand that by signing this waiver I do irrevocably and permanently give up all custody and other parental rights, I may have to such child. 9. That I understand that this Waiver is FINAL AND IRREVOCABLE and that I am permanently barred from contesting any proceeding for the adoption of the child after I sign this waiver. 10. That I waive any further service of summons or other pleadings in any proceeding to terminate parental rights, if any to this child, or any proceeding for adoption of this child. 11. That I understand that if a final judgment or order of adoption for this child is not entered, then any parental rights or responsibilities that I may have remain intact. 12. That I have read and understand the above and that I am signing it as my free and voluntary act. Dated: _______________________, _______ __________________________________________ Signature OATH I have been duly sworn and I state under oath that I have read and understood this Final and Irrevocable Waiver of Parental Rights of Putative or Legal Father. The facts contained in it are true and correct to the best of my knowledge. I have signed this document as my free and voluntary act in order to facilitate the adoption of the child. __________________________________________ Signature Subscribed and sworn to before me this _______ day of _______________________, _______ __________________________________________ Notary Public DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS