IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _________________________________ _________________________________ Petitioner CASE NO. __________________________ vs. _________________________________ _________________________________ Defendant SURRENDER OF UNBORN CHILD FOR PURPOSES OF ADOPTION I, _____________________________________________________, state: (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 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, and that I have not previously executed a consent or surrender with respect to 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. Surrender of Unborn Child for Adoption/p.1 Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com 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, EXCEPT THAT I HAVE THE RIGHT TO REVOKE THIS SURRENDER BY GIVING WRITTEN NOTICE OF MY REVOCATION NOT LATER THAN 72 HOURS AFTER THE BIRTH OF 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) ____________________________________ Witness ____________________________________ Date ) ) SS. COUNTY OF DEKALB ) I, ___________________________________________________________________________________________, (name and official title) STATE OF ILLINOIS 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 he signed and delivered such Surrender 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 _____. ) ) 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. G iven under my hand and notarial seal this ______ day of ____________________________, 20____. STATE OF ILLINOIS (OFFICIAL SEAL) _______________________________________ Notary Public Surrender of Unborn Child for Adoption/p.2 Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com