IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ STATUTORY CONSENT OF BIRTH PARENT 1. [Name, age and marital status of consenter] 2. [Name, sex and birth date of child] 3. [Relationship of consenter to child] 4. [Name of other parent of child] I hereby voluntarily and unconditionally consent to the adoption of the above named child. I understand that by signing this consent I indicate my intent to permanently give up all rights to this child. I understand that such child will be placed for adoption and I am voluntarily executing this consent without disclosure to me of the name or other identification of the adopting parent or parents. OR I understand that such child will be adopted by [name(s)] in whose custody and care the child has been since [date]. I understand I may revoke this consent to permanently give up all rights to this child by placing the revocation in writing and serving it upon the agency or adult to whom the child was relinquished. If I am the Birth Father or Putative Father of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within thirty (30) days after either American LegalNet, Inc. www.FormsWorkFlow.com the birth of the child or my execution of the consent, whichever occurs later, by delivering a written revocation to [INSERT THE NAME AND ADDRESS OF THE AGENCY COORDINATING THE ADOPTION] or [INSERT THE NAME AND ADDRESS OF AN ATTORNEY WHO REPRESENTS THE INDIVIDUAL RELINQUISHING PARENTAL RIGHTS OR PROSPECTIVE ADOPTIVE PARENT] or [INSERT THE COURT OF THE COUNTY IN WHICH THE VOLUNTARY RELINQUISHMENT FORM WAS OR WILL BE FILED]. If I am the Birth Mother of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within thirty (30) days after executing it by delivering a written revocation to [INSERT THE NAME AND ADDRESS OF THE AGENCY COORDINATING THE ADOPTION] or [INSERT THE NAME AND ADDRESS OF AN ATTORNEY WHO REPRESENTS THE INDIVIDUAL RELINQUISHING PARENTAL RIGHTS OR PROSPECTIVE ADOPTIVE PARENT] or [INSERT THE COURT OF THE COUNTY IN WHICH THE VOLUNTARY RELINQUISHMENT FORM WAS OR WILL BE FILED]. I have read and understand the above and I am signing it as a free and voluntary act. __________[SIGNATURE]_______ Type Name:____________________________ Address of Parent:____________________________ Date of Execution:____________________________ Place of Execution:____________________________ WITNESSES: (at least two) ________[SIGNATURE]__________ Type Name: Address: Relationship to Consenter: ________[SIGNATURE]__________ Type Name: Address: Relationship to Consenter: American LegalNet, Inc. www.FormsWorkFlow.com