IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _______________________________________________ _______________________________________________ Petitioner(s), vs. _______________________________________________ _______________________________________________ Respondent(s). ) ) ) ) ) ) ) CASE NO. ______________________________ FINAL AND IRREVOCABLE CONSENT TO ADOPTION I, ______________________________________________ of _____________________________________ ____________ (relationship, e.g. mother, father, guardian) a female/male child, state: That such child was born on ________________________ at _________________________________________________. That I reside at ______________________________________________________________________________________, County of __________________________________________ and State of _____________________________________________. That I am of the age of ____________ years. That I hereby enter my appearance in this 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 Final and Irrevocable Consent. That I do hereby consent and agree to the adoption of such child. That I wish to and understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such 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_____. ) ) County of _________________ ) STATE OF ILLINOIS _______________________________________________ SS. 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/she signed and delivered such consent as her/his free and voluntary act, for the specified purpose. I have fully explained that by signing such consent he/she is irrevocably relinquishing all parental rights to such child or adult and he/she has stated that such is his/her intention and desire. In Witness Whereof, I have hereunto affixed my signature this ___________ day of _____________________, 20_______. ________________________________________________ Final & Irrevocable Consent to Adoption Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com