JC-1636, 04/08 Consent to Termination of Parental Rights (Affidavit) 24724748.41(2)(c) and 48.41(2)(d), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF a person under the age of 18. Date of Birth Consent to Termination of Parental Rights (Affidavit) Case No. UNDER OATH, I STATE: 1. My name is . My address is . My date of birth is . 2. My child is not a member of or eligible for membership in an Indian tribe. 3. For stepparent adoptions: I am the mother father of this child The child was was not born during a marriage with the other parent. For non-marital, non-adjudicated alleged fathers: I have never been married to , mother of this child. I have never been adjudicated (formally determined by a court) to be the father of this child. I am aware that I am alleged to be the father of this child. I am not admitting or denying that I am the father of this child. 4. I know that a petition to terminate my parental rights has been or will be filed. 5. 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 this child, such as: Duty to support Right to custody and visitation Right to inherit 6. I wish to give up any parental rights that I may have to this child and consent to the court entering an order terminating my parental rights. 7. I give up the right to know of any future hearing or proceedings in this matter. 8. 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 FOR STEP PARENT ADOPTIONS, YOU MUST HAVE TWO WITNESSES SIGN BELOW IN ADDITION TO COMPLETING THE NOTARY SECT ION ABOVE. Signature of Witness Signature of Witness American LegalNet, Inc. www.FormsWorkFlow.com