State of Minnesota County Judicial District: Court File Number: Case Type: District Court Adoption � Stepparent In Re the Petition of: , Petitioner/Parent and , Petitioner/Stepparent To Adopt: , (child's current name) , (child's current name) , (child's current name) STATE OF MINNESOTA COUNTY OF ) ) SS ) [parent's name], being first duly sworn Consent of Parent to Adoption by Stepparent and Waiver of Notice of Adoption Hearing I, upon oath, depose and state as follows: 1. I was born on and reside at address], in the City of , State of [date of birth], am currently , County of . years of age, [street 2. I am the parent of the following: one] child who was born on _____________, State of [child's name], a male female [check [date of birth] in the City of . [child's name], a male female [check [date of birth] in the City of . [child's name], a male female [check [date of birth] in the City of . one] child who was born on _____________, State of one] child who was born on _____________, State of AD0203 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com one] child who was born on _____________, State of [child's name], a male female [check [date of birth] in the City of . 3. Of my own free will, and with a view to the future welfare of my child(ren), and in the presence of two competent witnesses, I hereby consent to the adoption of my above-named child(ren) by [stepparent's name]. 4. I hereby waive notice of any and all hearings now or hereafter related to the adoption of said child(ren). 5. I understand that I may, for any reason, withdraw this consent to adoption within the next ten (10) working days from the date this consent is signed by me. 6. I further understand that if I decide to withdraw my consent to this adoption, my withdrawal of my consent must be in writing and must be received by the Court at the following address no later than the tenth (10th) working day following the date upon which this consent is signed and acknowledged: [name of county] County District Court located at [street address], in the City of , and State of Minnesota, Zip Code [zip code]. 7. I understand that my consent will become irrevocable on the day following the tenth (10th) working day from the date this consent is signed and acknowledged, unless a Court later rules in writing that consent was obtained by fraud. PARENTAL RIGHTS NOTICE THE AGENCY RESPONSIBLE FOR SUPERVISING THE ADOPIVE PLACEMENT OF YOUR CHILD [OR THE PETITIONER IN THE CASE OF AN ADOPTION NOT SUPERVISED BY AN AGENCY] WILL SUBMIT YOUR CONSENT TO ADOPTION TO THE COURT. THE CONSENT ITSELF DOES NOT TERMINATE YOUR PARENTAL RIGHTS. PARENTAL RIGHTS TO A CHILD MAY BE TERMINATED ONLY BY AN ADOPTION DECREE OR BY A COURT ORDER TERMINATING PARENTAL RIGHTS. UNLESS THE CHILD IS ADOPTED OR YOUR PARENTAL RIGHTS ARE TERMINATED, YOU MAY BE ASKED TO SUPPORT THE CHILD. AD0203 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com The non-petitioning parent MUST sign the consent form in the presence of two competent witnesses and in front of a notary public or court administrator. Parent's Signature Dated: [Signature of parent � sign only in front of notary public and two witnesses] Witnesses' Signatures Dated: [Witness � sign only in front of notary public] Dated: [Witness � sign only in front of notary public] On this day of , , before me personally appeared the person described herein who executed the foregoing consent to adoption and waiver and acknowledged that such consent and waiver was freely given, and the persons who were present when such consent was executed. Notary Public AD0203 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com