my intent to permanently give up all rights to this
child.
I understand such child will be placed for adoption.
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 [30 days] 120 hours
after either 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 of the child) 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 [30 days] 120 hours 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 of the child) 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
20150HB1526PN2346 - 4 -
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