PROBATE COURT OF SHELBY 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 me and hereby acknowledge that I understand my rights under the laws of the State of Ohio as set forth below. I further acknowledge that my signature below is placed voluntarily, without the undue influence of any person. 1. The placement for purposes of adoption of an infant born to me on ______________________________________ is done by me, without the involvement of any person, institution or agency certified by the Department of Job and Family Services, except the assistance of __________________________________________________, Attorney at Law, who I understand represents the adoptive family in this matter. I do/do not (circle appropriate language) know the identity of the proposed adoptive family. 2. I understand that I am appearing before this Court today to request the approval of placement for purposes of adoption of ____________________________________________________________________________________ which placement, 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 placement is made by a public children services agency, an institution or association that is certified by the Department of Job and Family 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 placement 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 placement specified in the application and have signed and filed with the court a written statement showing that the parent or parents are aware of their right to contest the decree of adoption subject to the limitations of section 3107.16 of the Revised Code; B. The court ordered an independent home study of the proposed placement to be conducted as provided in section 3107.031 [3107.03.1] of the Revised Code, and after completion of the home study, the court determined that the proposed placement is in the best interest of the child; C. The court has approved of record the proposed placement. 1 SCPC FORM 305 ­ WRITTEN STATEMENT OF NATURAL PARENT American LegalNet, Inc. www.FormsWorkFlow.com 4. I further represent that I understand that the Final Order of Adoption is subject to appeal by me 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 my rights of appeal may expire. I understand that the Final Order of Adoption should be granted in approximately seven months, and that the normal right of appeal would expire 30 days from that day. If I have any question concerning contesting this adoption in any manner, I understand that I should immediately contact the Court and/or Legal counsel. 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 manner or upon any ground, including fraud, misrepresentation, failure to give any required notice, or lack of jurisdiction of the parties or of the subject matter, unless, in the case of the adoption of a minor, the petitioner has not taken custody of the minor, or, in the case of the adoption of a minor 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 placement that my consent will still be required before a petition to adopt this child may 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 minor is not voidable by reason of the minor's age. B. A consent to adoption may 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 minor for adoption. 8. I understand that the effect of the Interlocutory and Final Orders of Adoption is the termination of all legal relationships between myself and this child. The prospective adoptive parents will be established as the legal parents of this child, have the full and complete rights to determine the values and upbringing of the child, including but not limited to, the choice of religious training, education, and discipline. 2 SCPC FORM 305 ­ WRITTEN STATEMENT OF NATURAL PARENT American LegalNet, Inc. www.FormsWorkFlow.com 9. My name is _________________________________________________________________________________ My address is _________________________________________________________________________________ My date of birth is ______________________________________________________________________________ I execute this Written Statement in open Court on ______________________________________________