PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF THE PLACEMENT OF (Current name of child) CASE NO. WRITTEN STATEMENT OF NATURAL PARENT I, , have had the following paragraphs fully explained to m e and hereby acknowledge that I understand m y rights under the laws of the State of Ohio as set forth below. I further acknowledge that m y signature below is placed voluntarily, without the undue influence of any person. 1. The placem ent for purposes of adoption of an infant born to m e on is done by m e, without the involvem ent of any person, institution or agency certified by the Departm ent of Job and Fam ily Services, except the assistance of , Attorney at Law, w ho I understand represents the adoptive family in this matter. I do/do not (circle appropriate language) know the identity of the proposed adoptive fam ily. 2. I understand that I am appearing before this Court today to request the approval of placem ent for purposes of adoption of which placem ent, if approved, will occur today. 3. I represent to the Court that I understand that under Ohio law no child shall be placed or received for adoption or with intent to adopt unless placem ent is m ade by a public children services agency, an institution or association that is certified by the Departm ent of Job and Fam ily Services under section 5103.03 of the Revised Code to place children for adoption, or custodians in another state or foreign country or unless all of the following criteria are met: A. Prior to the placem ent and receiving of the child, the parent or parents of the child personally have applied to, and appeared before the probate court of the county in which the parent or parents reside, or in which the person seeking to adopt the child resides, for approval of the proposed placem ent specified in the application and have signed and filed with the court a written statem ent showing that the parent or parents are aware of their right to contest the decree of adoption subject to the lim itations of section 3107.16 of the Revised Code; B. The court ordered an independent hom e study of the proposed placem ent to be conducted as provided in section 3107.031 [3107.03.1] of the Revised Code, and after com pletion of the hom e study, the court determ ined that the proposed placem ent is in the best interest of the child; C. 4. The court has approved of record the proposed placem ent. I further represent that I understand that the Final Order of Adoption is subject to appeal by m e to the Court of Appeals for this County. However, I am giving up the right to receive notice of any hearing, or the issuance of either the Interlocutory or Final Order of Adoption, and therefore will not know specifically when m y rights of appeal m ay expire. I understand that the Final Order of Adoption should be granted in approxim ately seven m onths, and that the norm al right of appeal would expire 30 days from that day. If I have any question concerning contesting this adoption in any m anner, I understand that I should im m ediately contact the Court and/or Legal counsel. BCPC FORM 305 - WRITTEN STATEMENT OF NATURAL PARENT 5/10 American LegalNet, Inc. www.FormsWorkFlow.com 5. I further represent to the Court that I am aware of the provisions of section 3107.16 of the Revised Code that provides that: A. Appeals from the probate court are subject to the Rules of Appellate Procedure and, to the extent not in conflict with those rules, Chapter 2505, of the Revised Code. Unless there is good cause for delay, appeals shall be heard on an expedited basis. B. Subject to the disposition of an appeal, upon the expiration of one year after an adoption decree is issued, the decree cannot be questioned by any person, including the petitioner, in any m anner or upon any ground, including fraud, m isrepresentation, failure to give any required notice, or lack of jurisdiction of the parties or of the subject m atter, unless, in the case of the adoption of a m inor, the petitioner has not taken custody of the m inor, or, in the case of the adoption of a m inor by a stepparent, the adoption would not have been granted but for fraud perpetrated by the petitioner or the petitioner’s spouse, or, in the case of the adoption of an adult, the adult had no knowledge of the decree within the one-year period. 6. I further represent that I understand that if the Court approves this placem ent that m y consent will still be required before a petition to adopt this child m ay be granted. 7. I further represent that I understand that under section 3107.084 of the Revised Code: A. A consent to adoption is irrevocable and cannot be withdrawn after the entry of an interlocutory order or after the entry of a final decree of adoption when no interlocutory order has been entered. The consent of a m inor is not voidable by reason of the m inor’s age. B. A consent to adoption m ay be withdrawn prior to the entry of an interlocutory order or prior to the entry of a final decree of adoption when no interlocutory order has been entered if the court finds after hearing that the withdrawal is in the best interest of the person to be adopted and the court by order authorizes the withdrawal of consent. Notice of the hearing shall be given to the petitioner, the person seeking the withdrawal of consent, and the agency placing the m inor for adoption. 8. I understand that the effect of the Interlocutory and Final Orders of Adoption is the termination of all legal relationships betw een myself and this child. The prospective adoptive parents will be established as the legal parents of this child, have the full and com plete rights to determ ine the values and upbringing of the child, including but not lim ited to, the choice of religious training, education, and discipline. 9. My nam e is My address is My date of birth is I execute this W ritten Statem ent in open Court on (Date) (Signature of parent) , personally appeared and acknowledged the signing of docum ent to be her voluntary act and deed, having been duly cautioned and sworn. Notary Public/Judge/Magistrate American LegalNet, Inc. www.FormsWorkFlow.com