Probate Court of Cuyahoga County, Ohio Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF THE ADOPTION OF ________________________________________ CASE NUMBER:______________________________________ CONSENT TO ADOPTION [R.C. 3107.06, 3107.08 & 3107.081] The undersigned _______________________________________________________________________________ [check on of the following seven capabilities by which your consent is given] 9 Mother 9 Father 9 Putative father who has registered under R.C. 3107.062 (for a minor born on or after January 1, 1997) 9 Putative father (for a minor born before January 1, 1997) 9 Agency having permanent custody 9 Minor, who is more than twelve years of age (this consent must be executed in the presence of the court) 9 Other ______________________________________________________________ Hereby waives notice of the hearing of the Petition for Adoption to be filed in the court, and consents to the adoption of __________________________________________________________ as proposed in the petition. (Name before Adoption) The undersigned further states that this consent is voluntarily executed irrespective of disclosure of the name or other identification of the prospective adopting parents. ____________________________________________ Sworn to before me and signed in my presence this ____________ day of _______________________ , 20 __________ ___________________________________________ Person authorized pursuant to R.C. Chapter 3107 to take this acknowledgment ____________________________________________ Title form 18.3 - consent to adoption American LegalNet, Inc. www.FormsWorkflow.com