PROBATE COURT OF SUMMIT COUNTY, OHIO ELINORE MARSH STORMER, JUDGE ADOPTION OF CASE NO. (Name after adoption) 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 Parent Putative father who has registered under R.C. 3107.062 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 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. Signature Printed Name Sworn to before me and signed in my presence this day of , 20 . Person authorized pursuant to R.C. Chapter 3107 to take this acknowledgement Title FORM 18.3 ­ CONSENT TO ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com Rev. 04/08/2016