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Final And Irrevocable Consent For Adoption Form. This is a Illinois form and can be use in Sangamon Local County.
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Tags: Final And Irrevocable Consent For Adoption, Illinois Local County, Sangamon
In The Circuit Court
For The Seventh Judicial Circuit of Illinois
Sangamon County, Springfield, Illinois
}
(Petitioners)
VS.
Case Number:
(Defendants)
FINAL AND IRREVOCABLE CONSENT FOR ADOPTION
I
of
,
(Name)
,
(Relationship to child)
(Name of child)
at
a male/female child states: that such a child was born on
(Circle One)
(Date of Birth)
and that I reside at
,
(Address)
County of
That I am the age of
(Place)
(City/State/Zip)
, in the State of
.
years.
That I hereby enter my appearance in this proceeding and waive service of Summons on me.
That I do hereby consent and agree to the adoption of such child.
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 that such child will be placed for adoption and that I cannot under any circumstance after
signing this document, change my mind and revoke or cancel this Consent or obtain or recover custody of any
other rights over such child.
That I have read and understand the above and I am signing in as my free and voluntary act.
Date
Defendant(s)
Defendant(s)
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STATE OF ILLINOIS
SS.
County of Sangamon
I,
do hereby certify that
a person known to me to be the same person whose name is subscribed to the foregoing Consent, appeared
before me this day in person and acknowledged that he/she signed and delivered such Consent as his/her free
and voluntary act for the specified purpose.
I have fully explained that by signing such Consent, he/she is irrevocably relinquishing all parental rights to
such child and he/she has stated that such is his/her intention or desire.
In witness whereof I have here unto affixed my signature this date.
Date
Judge
STATE OF ILLINOIS
SS.
County of Sangamon
a Notary Public in and for said County, in the State aforesaid, do hereby
I,
certify that:
personally known to me to be the same person whose name is
subscribed to the forgoing Certificate acknowledged that he/she signed such Certificate as his/her voluntary
act and that statement made in said Certificate is true.
Given under my hand and Notarial Seal this date.
Date
(SEAL)
Notary Public
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