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: DCFS CASE I, __________________________________, the mother/father of ________________________ a male/female child, state that: 1. My child, ____________________________________, was born on ________________ at _____________________________ Hospital in the municipality of _______________ in ___________________________ County, State of ____________________________. 2. I reside at ______________________________________________________, County of ________________________, State of _________________________ Zip Code ______. Mail may also be sent to me at this address: _______________________________________ In care of: __________________________________________________________________ My home telephone number is: _________________________________________________ My cell telephone number is: ___________________________________________________ My e-mail address is: _________________________________________________________ 3. I, _______________________________________, am ________________ years of age. 4. I enter my appearance in this action for my child to be adopted by the person or persons specified herein by me and waive service of summons on me in this action only. 5. I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and Responsibilities in Illinois for Final and Irrevocable Consents to Adoption by a Specified Person or Persons for DCFS Cases before signing this Consent and that I have had time to read this form, or have it read to me, 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 this form, it shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person or Persons. 6. I do hereby consent to the adoption of such child by _____________________________ ________________________________________ only. Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.1 American LegalNet, Inc. www.FormsWorkFlow.com 7. I wish to sign this Consent and I understand that by signing this Consent, I irrevocably and permanently give up all my parental rights I have to my child. 8. I understand that this Consent allows my child to be adopted by ____________________ ________________________ only and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this Consent. If the parent consents to an adoption by two specified persons, complete the following: 8a. I understand that if ____________________________________________________ and ___________________________________ get a divorce or are granted a dissolution of a civil union before the petition to adopt my child is granted, this Consent remains valid for _________________________________________________ (identify specified person) to adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or revoke custody over my child if __________________________________ and _______________________________________ divorce or are granted a dissolution of a civil union. 8b. I understand that if either _________________________________________________ or ____________________________________ dies before the petition to adopt my child is granted, this Consent remains valid for the surviving person to adopt my child. I understand that I cannot change my mind and revoke this Consent or obtain or recover custody over my child on the basis that one of the specified persons dies. 9. I understand that this Consent will be void if: a. the Department places my child with someone other than the specified person or persons; or b. a court denies the adoption petition for the person or persons to adopt my child; or c. the DCFS Guardianship Administrator refuses to consent to my child's adoption by the specified person or persons on the basis that the adoption is not in my child's best interest. I understand that if this consent is void, I have parental rights to my child, subject to any applicable court orders including those entered under Article II of the Juvenile Court Act of 1987, unless and until I sign a new consent or surrender or my parental rights are involuntarily terminated. I understand that if this Consent is void, my child may be adopted by someone other than the specified person or persons only if I sign a new consent or surrender, or my parental rights are involuntarily terminated. I understand that if this Consent is void, the Department will notify me within 30 days using the addresses and telephone numbers I provided in paragraph 2 of this form. I understand that if I receive such notice, it is very important that I contact the Department immediately and preferably within 30 days, to have input into the plan for my child's future. 10. I understand that if a petition for adoption of my child is filed by someone other than ___ _________________________________________, the Department will notify me within 14 days after the Department becomes aware of the petition. If someone other than ____ _________________________________________ (specified person(s)) files a petition to adopt my child, this consent remains valid only for ______________________________ (specified person(s)) to adopt by child. Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.2 American LegalNet, Inc. www.FormsWorkFlow.com 11. If a person(s) other than the specified person or persons files a petition to adopt my child or if the consent is void under paragraph 9, the Department will send written notice to me using the mailing address and email address provided by me in paragraph 2 of this form. The Department will also contact me using the telephone numbers I provided in paragraph 2 of this form. It is very important that I let the Department know if any of my contact information changes. If I do not let the Department know of any of my contact information changes, I understand that I may not receive notification from the Department if this Consent is void or if someone other than the specified person or persons files a petition to adopt my child. If any of my contact information changes, I should immediately notify: Caseworker's n