Rev. 07/2018 KSJC 1 CONSENT TO ADOPTION OF MINOR CHILD NOTICE TO PARENT OR LEGAL GUARDIAN: This is an important legal document and by signing it you are permanently giving up all custody and other parental rights to the child named in this consent, so as to permit the child's adoption. You are to receive a copy of this document. I, , (mother, father, legal guardian) of , a minor child, state: 1. The child was born on (date of birth) at (place of birth) at .m. 2. I reside at, county of and state of . [My social security number is XX-XXXX- .] 3. I am years of age and was born in (year) . 4. [As required by law, as a minor I have been advised by independent legal counsel of the consequences of signing this consent, and counsel was present when I signed it.] 5. I consent and agree to the adoption of the child [by ] [and I do not require disclosure of the name or other identification of the adopting parent or parents]. 6. I wish to and understand that by signing this consent I do permanently give up all custody and other parental rights I have to the child. 7. I (was married to ) (was not married) at the time of the child222s (conception)(birth). [The father of the child is , whose present address is .] [There are no other possible fathers.] [ was determined to be the child222s father in District Court, case number .] [There is more than one possible father.] [The names and addresses of the possible fathers are: .] [The names and addresses of the possible fathers will be provided by separate affidavit.] 8. [To the best of my knowledge, neither the child nor I am a member of or eligible for membership in an Indian tribe recognized by federal law.] [To the best of my knowledge, the (father) (mother) is not a member of or eligible for membership in an Indian tribe recognized by federal law.] American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/2018 KSJC 2 [I am a member of the tribe, (address) .] [The child is a member of the tribe, (address) .] [The (father)(mother) is a member of the tribe, (address) .] 9. [I freely and voluntarily enter my appearance in any proceeding instituted in any court of competent jurisdiction for the adoption of the child. I choose (to receive) (not to receive) notice of the time, date and location of the final hearing. If I have chosen to receive notice, I request that the notice of final hearing be sent to me at the following address by regular mail at least 10 days prior to the hearing: .] 10. I am of sound mind and under no undue restraint or duress. I have read and understand the above and I am signing it as my free and voluntary act. Dated , at .m. (signature of parent or legal guardian) [Must be acknowledged either before a judge or a notary public. Choose the appropriate acknowledgment from the two options below.] ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT STATE OF ) ) COUNTY OF ) I, , Judge of (name and location of court) , certify that , known to me to be the same person whose name is signed on this consent, appeared before me this day in person and acknowledged that (she)(he) signed this consent as (her)(his) free and voluntary act, for the specified purpose. I have fully explained that by signing this consent (she)(he) is permanently giving up all parental rights to the child and (she)(he) has stated that such is (her)(his) intention and desire. Dated , at .m. (signature of judge) American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/2018 KSJC 3 ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER STATE OF ) ) COUNTY OF ) This consent was acknowledged before me on ( date ) at ( time ) by ( name of person ). (signature of notarial officer) (SEAL, if any) title (and rank) [My Appointment Expires: ] CERTIFICATE OF ATTORNEY FOR CONSENTING [MINOR] PARENT I am a licensed attorney representing , [who is a minor]. I have fully explained that by signing this consent is permanently giving up all parental rights to the child and (she)(he) has stated that such is (her)(his) intention and desire. I was present at the execution of this consent. Dated (signature of attorney) Authority: K.S.A. 59-2143 American LegalNet, Inc. www.FormsWorkFlow.com