IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _______________________________________________ _______________________________________________ Petitioner(s), vs. _______________________________________________ _______________________________________________ Respondent(s). ) ) ) ) ) ) ) ) ) ) ) CASE NO._______________________________ FINAL AND IRREVOCABLE SURRENDER FOR PURPOSES OF ADOPTION I, _________________________________________of ____________________________________________, (relationship) a ___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 do hereby surrender and entrust the entire custody and control of such child to the _________________________________________________________________________________________________ (Agency) a (public) (licensed) child welfare agency with its principal office in the City of __________________________________, County of _______________________________________, and State of ________________________________________, for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption and to consent to the legal adoption of such child. That I hereby grant to said Agency full power and authority to place such child with any person or persons it may in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of such child by such person or persons; and to take any and all measures which, in the judgment of said Agency, may be for the best interests of such child, including authorizing medical, surgical and dental care and treatment including inoculation and anesthesia for such child. That I wish to and understand that by signing this surrender I do irrevocably and permanently give up all custody and other parental rights I have to such child. THAT I UNDERSTAND I CANNOT UNDER ANY CIRCUMSTANCES, AFTER SIGNING THIS SURRENDER, CHANGE MY MIND AND REVOKE OR CANCEL THIS SURRENDER 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. ______________________________________ ____________________________________________ Signature Witness Dated this ________ day of _________________________, 20_____. Final & Irrevocable Surrender-Adoption Rev. 04-01-16/p.1 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ILLINOIS SS. COUNTY OF DEKALB I, _________________________________________________________________________________________, (name and official title) do hereby certify that ______________________________________, personally known to me to be the same person whose name is subscribed to the foregoing Surrender, appeared before me this day in person and acknowledged that (she) (he) signed and delivered such Surrender as (her) (his) free and voluntary act, for the specified purpose. I have fully explained that by signing such consent (she) (he) is irrevocably relinquishing all parental rights to such child or adult and (she) (he) has stated that such is (her) (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 Final & Irrevocable Surrender-Adoption Rev. 04-01-16/p.2 American LegalNet, Inc. www.FormsWorkFlow.com