Written Statement Of Biological Parent - Probate Court Of Fairfield County, Ohio
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PROBATE COURT OF FAIRFIELD COUNTY, OHIO
Terre L. Vandervoort, Judge
In the Matter of the PLACEMENT of:____________________________________________________________________
(Current name of child)
Case No. _____________________________
Date:__________ ____________
WRITTEN STATEMENT OF BIOLOGICAL PARENT
I, ______________________________, have had the following paragraphs fully explained to me and hereby
acknowledge that I understand my rights under the laws of the State of Ohio as set forth below. I further acknowledge
that my signature below is placed voluntarily, without the undue influence of any person.
The placement for purposes of adoption of an infant born to me on ________________________
1.
is done by me, without the involvement of any person, institution or agency certified by the
Department of Human Services, except the assistance of ______________________________,
Attorney at Law, who I understand represents the adoptive family in this matter . I do/do not
(circle appropriate language) know the identity of the proposed adoptive family.
I understand that I am appearing before this Court today to request the approval of placement for
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purposes of adoption of ________________________________ which placement, if approved,
will occur today.
I represent to the Court that I understand that under Ohio law no child shall be placed or received
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for adoption or with intent to adopt unless placement is made by a public children services
agency, an institution or association that is certified by the Department of Human Services under
Section 5103.03 of the Revised Code to place children for adoption, or custodians in another
state or foreign country or unless all of the following criteria are met:
Prior to the placement and receiving of the child, the parent or parents of
A.
the child personally have applied to, and appeared before the Probate
Court of the county in which the parent or parents reside, or in which the
person seeking to adopt the child resides, for approval of the proposed
placement specified in the application and have signed and filed with the
Court a written statement showing that the parent or parents are aware
of their right to contest the decree of adoption subject to the limitations of
Section 3107.16 of the Revised Code;
The Court ordered an independent home study of the proposed
B.
placement to be conducted as provided in Section 3107.031 [3107.03.1]
of the Revised Code, and after completion of the home study, the Court
determined that the proposed placement is in the best interest of the
child;
The Court has approved of record the proposed placement.
C.
I further represent that I understand that the Final Order of Adoption is subject to appeal by me to
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the Court of Appeals for this County. However, I am giving up the right to receive notice of any
hearing or the issuance of either the Interlocutory or Final Order of Adoption, and therefore will
not know specifically when my rights of appeal may expire. I understand that the Final Order of
Adoption should be granted in approximately seven months, and that the normal right of appeal
would expire 30 days from that day. If I have any questions concerning contesting this adoption
in any manner, I understand that I should immediately contact the Court and/or legal counsel.
FORM 19.13 - WRITTEN STATEMENT OF BIOLOGICAL PARENT
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