PROBATE COURT OF CLERMONT COUNTY, OHIO
JAMES A. SHRIVER, JUDGE
IN THE MATTER OF THE ADOPTION OF______________________________________________
(Name after adoption)
CASE NO.____________________________
CONSENT TO ADOPTION
[R.C. 3107.06, 3107.08 & 3107.081]
The undersigned ___________________________________________________________________________
[check one of the following seven capacities by which your consent is given]
Mother
Father
Parent
Putative father who has registered under R.C. 3107.062
Agency having permanent custody
Minor, who is more than twelve years of age (this consent must be executed in the presence of the
Court)
Other _______________________________________________________________________
hereby waives notice of the hearing on the Petition For Adoption to be filed in the court, and consents
to the adoption of __________________________________________________________________________
(Name before adoption)
as proposed in the petition.
The undersigned further states that this consent is voluntarily executed irrespective of disclosure of the name or
other identification of the prospective adopting parents.
_________________________________________
Sworn to before me and signed in my presence this ______ day of __________________________, _________
__________________________________________
Person authorized pursuant to R.C. Chapter 3107
to take this acknowledgement
_________________________________________
Title
FORM 18.3 - CONSENT TO ADOPTION
03/15/16