STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CONSENT BY PERSON (14 OR MORE YEARS OLD) TO BE ADOPTED 4 M.R.S. � 152(5-A) 1. I am the adoptee named above. I was born on years old. 2. I understand that a petition to adopt me has been filed by and I am ________ (petitioner(s)) who will become my legal parent(s). 3. I also understand that my name may be changed. 4. I hereby consent to my adoption by the petitioner(s) and for the change of my name. Dated: Signature of Adoptee Printed Name of Adoptee 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. Dated: Judge, Maine District Court Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com