IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _________________________________ _________________________________ Petitioner CASE NO. ______________________________ vs. _________________________________ _________________________________ Defendant CONSENT TO ADOPTION OF UNBORN CHILD I, ________________________________________________, state: (name of father) That I am the father of a child expected to be born on or about ________________________ to _________________________________________________. (name of mother) That I reside at _________________________________________________________, County of ___________________________________________ and State of ___________________________. That I am of the age of __________ years. That I hereby enter my appearance in such adoption proceeding and waive service of summons on me. That I hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and Responsibilities-Private Form before signing this Consent, and that I have had time to read, or have had read to me, this Form. I understand that if I do not receive any of the rights as described in this Form, it shall not constitute a basis to revoke this Consent to Adoption of Unborn Child. 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. 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. THAT I UNDERSTAND SUCH CHILD WILL BE PLACED FOR ADOPTION AND THAT 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 this ________ day of _________________________, 20_____. _________________________________________ (Signature) Consent to Adoption of Unborn Child/p.1 Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ILLINOIS COUNTY OF DEKALB ) ) SS. ) (name and official title) I, ____________________________________________________________________________, do hereby certify that ______________________________________, 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 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. In Witness Whereof, I have hereunto affixed my signature this ______ day of ______________, 20 _____. STATE OF ILLINOIS ) ) SS. COUNTY OF DEKALB ) I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that _____________________________________, personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (she) (he) signed such certificate as (her) (his) free and 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 to Adoption of Unborn Child/p.2 Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENT RIGHTS AND RESPONSIBILITIES-PRIVATE FORM (750 ILCS 50/10) As a birth parent in the State of Illinois, you have the right: 1. To have our own attorney represent you. The prospective adoptive parents may agree to pay for the cost of your attorney in a manner consistent with Illinois law, but they are not required to do so. 2. To be treated with dignity and respect at all times and to make decisions free from coercion and pressure. 3. To receive counseling before and after signing a Final and Irrevocable Consent to Adoption ("Consent"), a Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case ("Specified Consent"), or a Consent to Adoption of Unborn Child ("Unborn Consent"). The prospective adoptive parents may agree to pay for the cost of counseling in a manner consistent with Illinois law, but they are not required to do so. 4. To ask to be involved in choosing your child's prospective adoptive parents and to ask to meet them. 5. To ask your child's prospective adoptive parents any questions that pertain to your decision to place your child with them. 6. To see your child before signing a Consent or Specified Consent. 7. To request contact with your child and/or the child's prospective adoptive parents, with the understanding that any promises regarding contact with your child or receipt of information about the child after signing a Consent, Specified Consent, or Unborn Consent cannot be enforced under Illinois law. 8. To receive copies of all documents that you sign and have those documents provided to you in your preferred language. 9. To request that your identifying information remain confidential, unless required otherwise by Illinois law or court order, and to register with the Illinois Adoption Registry and Medical Information Exchange. 10. To work with an adoption agency or attorney of your choice, or change said agency or attorney, provided you promptly inform all of the parties currently involved. 11. To receive, upon request, a written list of any promised support, financial or otherwise, from your attorney or the attorney for your child's prospective adoptive parents. Consent to Adoption of Unborn Child/p.3 Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com 12. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready to do so. 13. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have received financial support from the prospective adoptive parents. If you do not receive any of the rights described in this Form, it shall not be a basis to revoke Consent, Specified Consent, or Unborn Consent. As a Birth Parent in the State of Illinois, you have the responsibility: