
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 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
14 DAYS 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 14 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 of the
20150HB1526PN3512 - 4 -
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