D.R.L. §§115, 115-b Form 2-F Judicial Consent Birth or Legal Parent Private-Placement) 8/2002 COURT OF THE STATE OF NEW YORK COUNTY OF ____________________________ In the Matter of the Adoption of A child whose First Name is Docket No. JUDICIAL CONSENT (Birth or Legal Parent -- Private-Placement) ____________________________ THIS CONSENT BECOMES IRREVOCABLE UPON EXECUTION OR ACKNOWLEDGMENT BEFORE ANY JUDGE OR SURROGATE IN NEW YORK STATE OR A COURT OF COMPETENT JURISDICTION IN ANOTHER STATE HAVING JURISDICTION OVER ADOPTION PROCEEDING(S). NO ACTION OR PROCEEDING FOR THE CUSTODY OF THE ADOPTIVE CHILD MAY BE MAINTAINED BY THE PARENT EXECUTING OR ACKNOWLEDGING THE WITHIN CONSENT. ; optional]: 1. I, [specify name]: , residing at (birth)(legal) parent of [specify first name]: , do hereby consent to the adoption of my son [specify date]: (by [specify name(s); optional]: adoptive parent(s)). , who was born on , 2. I have been advised that this consent becomes irrevocable when executed or acknowledged before a judge or surrogate, and thereafter no action or proceeding may be maintained by me for the custody of the child. I also have been advised that before I acknowledge or execute this consent, I have a right to be represented by a lawyer of my own choosing and, if I am financially unable to obtain same, a lawyer will be assigned at public cost. I further have been advised that I have a right to obtain supportive counseling. *3. The full name and last known address of the other legal parent of the adoptive child are: Dated: Signature: American LegalNet, Inc. www.USCourtForms.com Form 2-f Page 2 ______________________________________/______________________________ Birth parent: typed or printed name/ signature ______________________________________/________________________________ Attorney if any: typed or printed name/signature ______________________________________________________________________ Attorney's Address and Telephone number State of County of ) ss.: ) On [specify date]: , [specify name]: personally appeared before me. (He)(She) is personally known to me or proved (his)(her) identity to me by satisfactory evidence as the person whose name is subscribed on this judicial surrender. (He)(She) acknowledged to me that (he)(she) executed this surrender. I have informed (him)(her) of the consequences of the act of execution and acknowledgment pursuant to the provisions of section 115-b of the Domestic Relations Law and have informed (him)(her) of the right to be represented by legal counsel of (his)(her) own choosing; of the right to obtain supportive counseling and of any rights to assigned counsel pursuant to section 262 of the Family Court Act, section 407 of the Surrogate's Court Procedure Act, or section 35 of the Judiciary Law. I have given (him)(her) a copy of this consent upon execution thereof. _______________________________________ Judge of the Court (Seal of Court to be affixed together with Court Clerk's certification) American LegalNet, Inc. www.USCourtForms.com