Out-Of-Court Consent To Direct Placement Adoption By Parent Page 2

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[Instructions: Initial each line only after reading and fully understanding each paragraph]
8. ______ It has been explained to me and I understand all of the following:
a. I am not required to sign an out-of-court consent.
b. I may make a temporary placement of my child with the prospective adoptive parent(s), if I have
not already done so, or I may continue the temporary placement I have already made, until I
choose to sign a consent in court or sign an out-of-court consent.
c. I may request revocation of the out-of-court consent I have signed by submitting a timely written
request for revocation.
d. If I request a revocation of the out-of-court consent, I must appear before the court so the court
may consider whether to grant the revocation.
9. _____ I have been advised that I may submit a request for revocation in writing to the adoption attorney or
child placing agency that witnessed my out-of-court consent not more than 5 days, excluding
weekends and holidays, after the out-of-court consent was signed, or I may petition the court on my
own for revocation of the out-of-court consent not more than 5 days, excluding weekends and
holidays, after the out-of-court consent was signed.
a. A request for revocation may not be submitted to the adoption attorney representing the parent
or to a caseworker from the child placing agency that witnessed the out-of-court consent by
telephone or text message.
b. A written request for revocation may be sent to the adoption attorney who represents the parent
at the following postal mailing and/or overnight carrier address:
____________________________________________________________________________
The fax number of the adoption attorney is: _________________________________________
The email address of the adoption attorney is: _______________________________________
c. A written request for revocation may be sent to a caseworker from the child placing agency that
witnessed the out-of-court consent at the following postal mailing and/or overnight carrier
address:
____________________________________________________________________________
The fax number of the child placing agency is: ________________________________________
The email address of the child placing agency is: ______________________________________
d. A petition for revocation of consent may be filed with the court at the following address:
____________________________________________________________________________
10. _____ I have been advised if I submit a timely request for revocation, the court may grant the request or
deny the request for revocation depending on my fitness and immediate ability to properly care for the
child and whether the best interests of the child would be served by the revocation.
11. _____ I understand my right to request a rehearing or appeal within 21 days after an order is entered
terminating my parental rights.
12. _____ I understand that my parental rights may be reinstated without further hearing if the adoption of the
child named above is not confirmed.
I ACKNOWLEDGE THAT I AM SIGNING THIS OUT-OF-COURT CONSENT FREELY AND
VOLUNTARILY, AFTER MY PARENTAL RIGHTS HAVE BEEN EXPLAINED TO ME AND ANY
QUESTIONS I MAY HAVE ABOUT IT HAVE BEEN FULLY ANSWERED. I UNDERSTAND THE
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