PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE ADOPTION (Name after adoption) CASE NO. CONSENT TO ADOPTION [R.C. 3107.06, 3107.08 & 3107.081] The undersigned [check one of the following seven capacities by which your consent is given] Mother Father Putative father who has registered under R.C. 3107.062 (for a minor born on or after January 1997) Putative father (for a minor born before January 1, 1997) Agency having permanent custody Minor, who is more than twelve years of age (this consent must be executed in the presence of the Court) Other hereby waives notice of the hearing on the Petition For Adoption to be filed in the court, and consents to the adoption of (Name before adoption) as proposed in the petition. 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 , . Person authorized pursuant to R.C. Chapter 3107 to take this acknowledgement Title FORM 18.3 - CONSENT TO ADOPTION 10/1/97 American LegalNet, Inc. www.FormsWorkFlow.com