Petition For Adoption Form Page 6
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6DISTRICT COURT, COUNTY OF _______________________________, STATE OF MINNESOTA
CONSENT OF CHILD OVER FOURTEEN YEARS OF AGE
The undersigned, being the child mentioned in the foregoing petition, hereby consents that (s)he be
adopted by _______________________________ and __________________________________, his wife.
In Presence of:
___________________________________
(Witness)
___________________________________
______________________________________
(Witness)
STATE OF MINNESOTA
COUNTY OF ____________________
On this ______________ day of _________________________, _______, before me personally
appeared ________________________ , to me known to be the person described in, and who executed the
foregoing consent, and acknowledged that ___he executed the same as h___ free act and deed.
____________________________________
Notary Public
___________ County, State of Minnesota
______________________________________
My Commission Expires ________________
Commissioner of Human Services, his agent or
Representative of Licensed Child-Placing Agency
STATE OF MINNESOTA
COUNTY OF ____________________
On this ___________ day of ______________________, _____, before me personally appeared
__________________________________, to me known to be the Commissioner of Human Services, his agent,
or a representative of a Licensed Child-Placing Agency and known to me to be personally present when
________________________________ executed the foregoing consent.
____________________________________
Notary Public
___________ County, State of Minnesota
My Commission Expires ________________
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