Appearance Waiver And Consent To Adoption Page 2
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1
2OC-292
A
Doc. Code: AWCA
Rev. 5-06
CONSENT TO ADOPTION
Page 2 of 2
I, ____________________________________________, hereby state that I am the natural [ ] mother [ ] father
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(parent's name)
of ______________________________________________________________________, the child to be adopted,
(child's name)
who was born to me [ ] in wedlock [ ] out-of-wedlock on __________________________________________
(child's date of birth)
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in ________________________________________________________________________________________.
(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consent and that this consent may be withdrawn only by written notification sent to the proposed adoptive parent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 ______________ a.m./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
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