STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CONSENT OF PARENT TO ADOPTION 4 M.R.S. � 152(5-A) , am: I, (check one of the following) the biological and/or legal father of the above named minor adoptee. the biological and/or legal mother of the above named minor adoptee. 1. I understand that a petition to adopt my child is currently pending and upon this adoption my child will become the legal child of the petitioner(s) who will assume all parental rights and responsibilities with respect to my child. 2. I wish to consent and voluntarily agree to this adoption. I understand that this consent is final and irrevocable once duly executed. 3. I understand that I am consenting only to the currently pending adoption. 4. Check the following if desired: I ask the Court to place in the decree of adoption a special entry that will preserve to my child the right to inherit from my kin and me. 18-A M.R.S. � 9-105 5. I understand that I have the right to obtain a lawyer's advice before signing this consent and that if I want a lawyer and cannot afford one, a lawyer can be assigned to represent me. 6. I have been advised that the Court may approve my consent only if the following conditions are met: A licensed child placing agency or the Department of Health and Human Services certifies to the Court that counseling was provided or was offered and refused (this requirement does not apply if one of the petitioners is a blood relative); and The Court has explained my parental rights and responsibilities and the effects of the consent; and that I have the right to revoke this consent within 3 days; and AD-013, Rev. 10/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com The Court has informed me of the existence of the adoption registry and the services available under 22 M.R.S. � 2706-A; and The Court determines that this consent has been duly executed and was given freely after I was informed of my rights; and The Court determines that this consent is in the child's best interest. 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: Signature of Consenting Parent STATE OF MAINE , ss. Personally appeared the above named , who under penalty of perjury, affirmed the truth of the facts in the foregoing consent as far as known or informed and freely and with full knowledge of the consequences, executed this consent as of the date above written Dated: District Court Judge WITHDRAWAL OR REVOCATION (Before District Court Judge) I hereby withdraw or revoke this consent. Dated: Signature of Parent Dated: District Court Judge APPROVAL This matter has been received by the Court and docketed. I find this consent to be in the best interest of the child. I hereby approve this consent. Dated: District Court Judge AD-013, Rev. 10/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com