STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CONSENT OF PARENT TO ADOPTION (OUTSIDE THE STATE OF MAINE) 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 an the effects of the consent; and that I have the right to revoke this consent within 3 days; and The Court has informed me of the existence of the adoption registry and the services AD-014, Rev. 10/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 DUE EXECUTION Personally appeared the above named consenting parent, (mother) (father) 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: Party Authorized to Take Consent STATE OF _________________________, ___________________________ COUNTY I, _________________________________________________, presiding in a court of comparable jurisdiction to that of the State of Maine District Court, in and for the County of ___________________ in the state of ______________________ do hereby certify that _____________________(mother) (father) (the "Consenting Parent") appeared before me on (date)______________________ and I followed the procedure to make a consent valid in the State of ___________________________ and has executed the same. Dated: Judge / Judge of Probate / Presiding Judge Seal IN WITNESS WHEREOF, I have hereunto set my hand and affixed the Official Seal of said Court this _____________ day of ____________ in the year of ___________. _ Judge / Judge of Probate / Presiding Judge AD-014, Rev. 10/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com