FINAL AND IR R EVOCABLE CONS ENT TO ADOPTION 3262 (Rev. 07/05) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT IN THE MATTER OF THE PETITION FOR ADOPTION OF: CASE NUM BER FINAL AND IRREVOCABLE CONSENT TO ADOPTION I, , [STATE RELATIONSHIP] , a [female] [male] child state: of That I reside at: , County of : And State of: That I am the age of: years. That I hereby enter my appearance in this proceeding and waive service of summons on me. 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 , A.D. 20 Signature Witness: Title: CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, IL LINOIS 60189-0707