IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _______________________________________________ _______________________________________________ Petitioner(s), vs. _______________________________________________ _______________________________________________ Respondent(s). ) ) ) ) ) ) ) ) CASE NO. ______________________________ CONSENT BY ADULT OR CHILD OF THE AGE OF FOURTEEN YEARS OR OVER TO ADOPTION I, ______________________________________________________________, state: That I reside at __________________________________________________________, County of_____________________________ and State of _______________________________________. That I hereby enter my appearance in this proceeding and waive service of summons on me. That I am of the age of ____________ years. That I consent and agree to my adoption by ________________________________________________________________________ and _________________________________________________. Dated this__________ day of __________________________, 20_______. STATE OF ILLINOIS ) ) SS. COUNTY OF ___________________ ) _______________________________________________ I, ________________________________________________________________________________________, do hereby certify that (Name and Official Capacity) ________________________________________ personally known to me to be the same person whose name is subscribed to the foregoing consent, appeared before me this day in person and acknowledged that he/she signed and delivered such consent as her/his voluntary act, for the specified purpose. I have fully explained that by signing such consent he/she is irrevocably electing to become, to all legal intents and purposes, the child of the Petitioner _____ named in said Petition, and he/she has stated that such is his/her intention or desire. IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____________________, 20_______. _______________________________________________ _______________________________________________ STATE OF ILLINOIS ) ) SS. COUNTY OF ___________________ ) I, ____________________________________________________, a Notary Public in and for said County, in the State aforesaid, do hereby certify that the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me this day in person and acknowledged that he/she signed such certificate as his/her voluntary act and that the statements made in said certificate are true. Given under my hand and notarial seal this ___________ day of _____________________, 20_______. (Official Seal) _______________________________________________ Notary Public Consent by Adult to Adoption Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com