Form Aoc-292 - Appearance Waiver And Consent To Adoption (Page 2 of 2) in pdf

AOC-292

Rev. 6-17

CONSENT TO ADOPTION

Page 2 of 2

I, ______________________________________________, hereby state that I am the natural q mother q father of

(parent's name)

_______________________________________________, the child to be adopted, who was born to me q in wedlock

(child's name)

q out-of-wedlock on __________________ in ________________________________________________________.

(child's date of birth)

(city, state, country of child's birth)

I also state, and acknowledge by my initials, that:

_____ I do not desire to know the identification of the proposed adoptive parent(s) of my child; or

_____ The proposed adoptive parent of my child is:______________________________________________.

_____ I understand that if the adoption is not adjudged, that the disposition of my child will be made pursuant to KRS 199.550.

_____ The total amount of my legal fees related to the execution of this consent are $__________________ to be paid

by_______________________________________.

_____ That I have reviewed this consent and the legal effect of this consent has been fully explained to me.

_____ That I have not been coerced in any way to execute this consent, nor have I been given or promised anything of

value, except those expenses allowable under KRS 199.590(6), to execute this consent.

_____ That it is my intention to consent to the adoption of my child.

I understand that this consent to the adoption of my child will become final and irrevocable twenty (20) days after the

later of the placement approval (if required by the secretary for families and children) or the execution of this consent and

that this consent may be withdrawn only by written notification sent to the proposed adoptive parent or the attorney

for the proposed adoptive parent on or before the twentieth day by certified or registered mail and also by first class

mail. If placement approval by the secretary is not required, the voluntary and informed consent shall become final and

irrevocable twenty (20) days after execution.

I hereby acknowledge, by my signature, executed this ______ day of _________________________, 2______ in

___________________________, __________________________ County, Kentucky at __________ q a.m. q p.m.

that I have voluntarily and knowingly given my informed consent to the adoption of my child.

____________________________________________

Consenting Parent's Signature

SUBSCRIBED and SWORN to before me this ___________ day of _______________________________, 2_______.

My Commission expires: __________________________.

____________________________________________

Notary Public

Preparer's Name & Address

Reviewer's Name & Address

__________________________________________

I received a completed and signed copy of this consent on the same day I signed it.

____________________________________________

Consenting Parent's Signature

SUBSCRIBED and SWORN to before me this ___________ day of _______________________________, 2_______.

My Commission expires: __________________________.

____________________________________________

Notary Public

Form Aoc-292 - Appearance Waiver And Consent To Adoption Page 2

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