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 ) Consent to Adoption by Child Age 14 or Older I, oath, depose and state as follows: 1. I was born on of age, and I reside at address], in the City of , State of [child's name], being first duly sworn upon [date of birth], I am currently , County of . years [street 2. Of my own free will, and in the presence of two competent witnesses, I hereby consent to being adopted by the Petitioner [stepparent's name]. Child's Signature Dated: [Signature of child ­ 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 and acknowledged that such consent was freely given, and the persons who were present when such consent was executed. Notary Public AD0204 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com