JC-1637, 02/18 Consent to Termination of Parental Rights (Judicial) 24748.41(2)(b), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF a person under the age of 18 Date of Birth Consent to Termination o f Parental Rights (Judicial) Case No. UNDER OATH, I STATE: 1. My name is . My address is . My date of birth is . 2. I am a parent or alleged to be a parent of the above - named child. 3. The above - named child is not a member of or eligible for membership in an Indian tribe. [For an Indian child, use the Indian Child Welfare Act version (IW - 1637) form.] 4. I have been informed and understand that a court order terminating parental rights will permanently end ALL legal rights and duties that exist between myself and the above - named child, such as: duty to support. right to custody and visitation. right to inherit. 5. I wish to give up any parental rights that I may have to the above - named child and consent to the court entering an order terminating my parental rights. 6. I give up the right to know of any future hearing or proceedings in this matter. 7. I am making this decision on my own free will. No promises or threats have been made to get me to sign this document. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Signature Name Printed or Typed Date APPROVAL OF GUARDIAN AD LITEM (Needed for minor or incompetent parent) I am the guardian ad litem for the above - named parent who is a minor or incompetent . I am familiar with the facts. I join in rights. CERTIFICATE OF JUDGE I certify that I am the judge of the court of County, State of , a court of record. The above - named parent appeared before me on this date. I questioned this parent and found this consent to be informed and voluntary before I accepted it. Guardian ad Litem Name Printed or Typed Date Judge Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com