STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CONSENT OF OTHER THAN PARENT 4 M.R.S. � 152(5-A) , am (check one of the following): I, an officer of the Maine Department of Health and Human Services authorized by law to execute this consent. an officer of placement agency in this consent. the legal guardian of the above named adoptee. the legal custodian of the above named adoptee. In accordance with 18-A M.R.S. � 9-302(a)(3), I hereby consent to the adoption of the above named adoptee by __________ (name) and _____________________________________________ (name). Dated: Name and title of officer, guardian or custodian executing this consent , a duly licensed child , authorized by law to execute STATE OF MAINE , ss. Personally appeared the above named , who under penalty of perjury, affirmed the truth of the foregoing statements and acknowledged his/her signature thereon to be genuine and to have been executed as his/her act and deed of the organization he/she represents. I am not an attorney nor a partner, associate or employee of an attorney for the adopting parents. Dated: District Court Judge/Notary Public AD-003, Rev. 7/16 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com