Consent by Indian Child222s Parent for Termination of - Page 1 of 4 Parental Rights and for Adoption (CON) WPF JU 03.0930 (10/2017) - RCW 13.38.150; 25 U.S.C. 2471913(a); 25 C.F.R. 247 23.124-.126, .128 SUPERIOR COURT OF WASHINGTON COUNTY OF JUVENILE COURT Dependency of: D.O.B.: No : Consent by Indian Child222s Parent for Termination of Parental Rights and for Adoption (CON) I. Consent 1.1 I am the parent of the above identified child. The child was born more than ten (10) days prior to the date on which I signed this consent. 1.2 There is reason to know the child is: (1) a member of a federally recognized tribe, or (2) eligible for membership in a federally recognized tribe and the biological child of a parent who is a member, based upon the following: . 1.2.1 The name of the child222s tribe or tribes is: . 1.2.2 The child222s and parent222s/parents222 tribal membership/enrollment numbers or other indication of the child222s membership in the tribe is as follows: . 1.3 I understand that I have the right to obtain the advice and representation of an attorney regarding relinquishment and termination of my parental rights. 1.4 I understand that my decision to relinquish the child is an extremely important one. I understand that after I sign this consent in court and it is approved by the court, an order permanently terminating my parental rights will be entered. This termination order will take away all my legal rights and obligations as a parent, except for my rights to withdraw this consent as set forth in Paragraphs 1.9, 1.10 and 1.11 below. However, any support obligation existing prior to the effective date of order terminating my parental rights will remain in full force and effect. I also understand that there are social services and counseling services available in the community, and that there may be financial assistance available through state and local governmental agencies. 1.5 I confirm that I desire to and consent to relinquish custody of the child to (DSHS/Supervising Agency) and authorize the agency to have custody of the child and to have the American LegalNet, Inc. www.FormsWorkFlow.com Consent by Indian Child222s Parent for Termination of - Page 2 of 4 Parental Rights and for Adoption (CON) WPF JU 03.0930 (10/2017) - RCW 13.38.150; 25 U.S.C. 2471913(a); 25 C.F.R. 247 23.124-.126, .128 power and authority to authorize and provide all necessary care for the child, which shall include but not be limited to, foster care, medical care, dental care, evaluations of the child, and placement of the child for adoption. 1.6 I hereby consent to termination of my parental rights and request the Court to enter an order permanently terminating all of my parental rights to the child. I further authorize the agency to consent, on my behalf, to the child's adoption. 1.7 Upon court approval of this consent, the court will enter an order permanently terminating my parental rights. 1.8 I understand that the legal effect of an order permanently terminating my parental rights will be to divest me of all legal rights and obligations with respect to the child, except for my rights to withdraw this consent as set forth in Paragraphs 1.9, 1.10, and 1.11 below. I also understand that the child will be freed from all legal obligations of obedience and maintenance with respect to me, and shall be, to all legal intents and purposes, and for all legal incidents, the child, legal heir, and lawful issue of the ultimate adoptive parents, entitled to all rights and privileges, including the right of inheritance and the right to take under testamentary disposition, and subject to all obligations of a child of such adoptive parents as if born to such adoptive parents. I further understand that after my parental rights are terminated, I am not thereafter entitled to notice of proceedings regarding the child's adoption, nor do I have any right to contest the adoption or otherwise participate in the child's adoption proceedings, except as set forth in Paragraphs 1.9, 1.10, and 1.11 below. 1.9 I also understand that an order permanently terminating my parental rights will not disentitle the child to any benefit due the child from any third person, agency, state, or the United States nor will the termination order affect any rights or benefits that the child derives or may be entitled to derive from any federally recognized Indian tribe of which the child is a member. I also understand that the child, upon reaching the age of eighteen (18) years, shall have the right to request and receive information regarding my tribal affiliation or other such information as may be necessary for the child's enrollment as a member in the tribe or for determining or protecting any rights or benefits associated with tribal membership. 1.10 I understand that I have the right to withdraw this consent for any reason and at any time before the court enters an order terminating parental rights or a final decree of adoption regarding the child. I understand that an order of termination will not be entered until a minimum of forty-eight (48) hours after I sign the consent in court. I also understand that if I wish to withdraw my consent, I must withdraw it in one of the following ways: (i) I may withdraw in a writing delivered or mailed to the clerk of the court and the withdrawal will be effective if received by the clerk of the court prior to entry of the order terminating parental rights or the final decree of adoption; (ii) I may withdraw my consent orally to the court at any time prior to entry of the order terminating parental rights or the final decree of adoption. 1.11 I understand that, if I withdraw this consent before the court enters an order terminating parental rights or a final decree of adoption regarding the child, I have the right to have the child promptly returned to my custody, unless the child has been taken into custody pursuant to RCW 13.34.050 or 26.44.050, placed in shelter care pursuant to RCW 13.34.060 , or placed in foster care pursuant to RCW 13.34.130 . 1.12 I understand that after the court enters a final decree of adoption I may withdraw this consent if it was obtained through fraud or duress. If the court finds that my consent was obtained through fraud or duress, the court will vacate the decree of adoption and return the child to me, except that, after the adoption has been in effect for two years, the court cannot invalidate it for fraud or duress unless otherwise allowed by state law. 1.13 This consent is voluntarily executed with or without disclosure of the name or other identification of the prospective adoptive parents. American LegalNet, Inc. www.FormsWorkFlow.com Consent by Indian Child222s Parent for Termination of - Page 3 of 4 Parental Rights and for Adoption (CON) WPF JU 03.0930 (10/2017) - RCW 13.38.150; 25 U.S.C. 2471913(a); 25 C.F.R. 247 23.124-.126, .128 1.14 Except as otherwise specifically described in this paragraph, no promises have been made to me, as a condition of my consent, regarding the tribal affiliation, health, ethnic, religious, economic, or other personal characteristics of any prospective adoptive family with whom the child will be placed. 1.15 I understand that this consent is not valid and has no force and effect unless I sign the consent in court and unless the consent is approved by the court. 1.16 The address of the clerk of the court where the consent will be presented for court approval is: . 1.17 I waive notice of further proceedings in this matter, except for any proceeding held to obtain court approval of this consent. 1.18 I have read or have had read to me the foregoing and I understand the same. The foregoing consent has been given freely, voluntarily, and with full knowledge of the consequences as stated above, and the consent is not the result of fraud or duress, nor am I acting under the influence of anyone. I certify under penalty of perjury under the laws of the state of Washington that the foregoing statement is true and correct. Dated at (city), (state) on (date). Signature Print or Type Name Address Telephone Number Signature of Parent222s Lawyer Print or type Name WSBA No. Witness Address of Witne