IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS IN THE MATTER OF THE ADOPTION OF: ) ) ) ____________________________________ ) A Minor CASE NO. _______________________________ FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR PERSONS: NON-DCFS CASE I, _______________________________________________________ state: 1. That I am the mother/father of _______________________________________________ a male/female child born on ___________________________________________, at ________________________________, City of ________________________________ and State of _____________________________. 2. That I reside at _______________________________________________, County of ____________________________ and State of ________________________________. 3. That I am the age of ____________________ years. 4. That I hereby enter my appearance in this proceeding and waive service of summons on me. 5. That I hereby acknowledge that I have been provided a copy of the Birth Parents 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 and that I understand the Rights and Responsibilities described in this Form. I understand that if I do not receive any of my rights as described in said Form, it shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person. 6. That I do hereby consent and agree to the adoption of such child by ________________ ______________________________________________________________ (specified person or persons) only. 7. That I wish to and understand that upon signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child if such child is adopted by ______________________________________________________ (specified person or persons). I hereby transfer all of my rights to the custody, care and control of such child to ___________________________________________________ ___________________________________ (specified person or persons). 8. That I understand such child will be adopted by ________________________________ ___________________________________ (specified person or persons) and that I cannot under any circumstances, after signing this document, change my mind and evoke Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.1 American LegalNet, Inc. www.FormsWorkFlow.com or cancel this consent or obtain or recover custody or any other rights over such child if ________________________________________________________________________ (specified person or persons) adopt(s) such child; PROVIDED that each specified person has filed, or shall file, within 60 days from the date hereof, a petition for the adoption of such child. 9. That if the specified person or persons designated herein do not file a petition for adoption within the time-frame specified above, or, if said petition for adoption is filed within the time-frame specified above but the adoption petition is dismissed with prejudice or the adoption proceeding is otherwise concluded without an order declaring the child to be the adopted child of the specified person or persons, then I understand that I will receive written notice of such circumstances within 10 business days of their occurrence. I understand that the notice will be directed to me using the contact information I have provided in this Consent. I understand that I will have 10 business days from the date that the written notice is sent to me to respond, within which time I may request the Court to declare this Consent voidable and return the child to me. I further understand that the Court will make the final decision of whether or not the child will be returned to me. If I do not make such request within 10 business days of the date of the notice, then I expressly waive any other notice or service of process in any legal proceeding for the adoption of the child. 10. That I expressly acknowledge that nothing in this Consent impairs the validity and absolute finality of this Consent under any circumstance other than those described in paragraph 9 of this Consent. 11. That I understand that I have a remaining duty and obligation to keep _______________ _________________________________________________________ (insert name and address of the attorney for the specified person or persons) informed of my current address or other preferred contact information until this adoption has been finalized. My failure to do so may result in the termination of my parental rights and the child being placed for adoption in another home. 12. That I do expressly waive any other notice or service of process in any of the legal proceedings for the adoption of the child as long as the adoption proceedings by the specified person or persons is pending. 13. That I have read and understand the above and I am signing it as my free and voluntary act. 14. That I acknowledge that this Consent is valid even if the specified person or persons separate or divorce or one of the specified persons dies prior to the entry of the final judgment for adoption. ___________________________________ Signature of Biological Parent ___________________________________ Address of Biological Parent ____________________________________ Phone Number(s) of Biological Parent ____________________________________ Personal email(s) of Biological Parent Dated this ______ day of __________________ 20 ______, at _________o'clock a.m. / p.m. Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.2 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS STATE OF _____________________________ ) ) ) COUNTY OF ___________________________ ) CASE NO. ____________________________ CERTIFICATE OF ACKNOWLEGEMENT OF CONSENT FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR PERSONS: NON-DCFS CASE I, ____________________________________________________________ (name of Judge or other person), _____________________________________________________ (official title, name and address), certify that ____________________________________________________ personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent for Adoption by a Specified Person or Persons, non-DCFS case, appeared before me this day in person and acknowledged that (she)