Consent To Adoption Of Minor Child Page 2
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1
2
3
4
5Dated
, at
.m.
)
(signature of parent or legal guardian
[Must be acknowledged either before a judge or a notary public. Choose the
appropriate acknowledgment from the two options below.]
ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT
STATE OF
)
) ss:
COUNTY OF
)
I,
, Judge of
, certify that
(name and location of court)
, known to me to be the same person whose name is
subscribed to the foregoing consent, appeared before me this day in person and
acknowledged that (she)(he) signed such consent as (her)(his) free and voluntary act, for
the specified purpose.
I have fully explained that by signing such relinquishment (she)(he) is permanently
giving up all parental rights to such child and (she)(he) has stated that such is (her)(his)
intention and desire.
Dated
, at
.m.
(signature of judge)
ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER
STATE OF
)
) ss:
COUNTY OF
)
I, a notarial officer in and for the county and state aforesaid, certify that
__________________, known to me to be the same person whose name is subscribed to
the foregoing consent, appeared before me in person and acknowledged that the
statements made in said consent are true.
Dated
at
.m.
(signature of Notarial Officer)
(
)
SEAL, if any
title (and rank)
[My Appointment Expires: _________ ]
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