Rep. Sara Feigenholtz
Filed: 3/4/2010
 
 

 




 

 		












09600HB6080ham001

LRB096 18717 AJO 38110 a






1

AMENDMENT TO HOUSE BILL 6080 




2
    AMENDMENT NO. ______. Amend House Bill 6080 by replacing 
3
everything after the enacting clause with the following:


 
 
4
    "Section 5. The Adoption Act is amended  by changing Section 
5
10 as follows:
 



6
    (750 ILCS 50/10)  (from Ch. 40, par. 1512)



7
    Sec. 10. Forms of consent and surrender; execution and

8
acknowledgment thereof.    A. The form of consent required for 
9
the
adoption of a born child shall be substantially as follows:

10

FINAL AND IRREVOCABLE CONSENT TO ADOPTION


11
    I, ...., (relationship, e.g., mother, father, relative, 
12
guardian)
of ...., a ..male child, state:

13
    That such child was born on .... at ....

14
    That I reside at ...., County of ....  and State of ....

15
    That I am of the age of .... years.

16
    That I hereby enter my appearance in this proceeding and 
 


 






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1
waive
service of summons on me.

2
    That I hereby acknowledge that I have been provided with a 
3
copy of the Birth Parent Rights and Responsibilities-Private 
4
Form before signing this Consent and that I have had time to 
5
read, or have had read to me, this Form. I understand that if I 
6
do not receive any of the rights as described in this Form, it 
7
shall not constitute a basis to revoke this Final and 
8
Irrevocable Consent. 
9
    That I do hereby consent and agree to the adoption of such 
10
child.

11
    That I wish to and understand that by signing this consent 
12
I do
irrevocably and permanently give up all custody and other 
13
parental
rights I have to such child.

14
    That I understand such child will be placed for adoption 
15
and that I
cannot under any circumstances, after signing this 
16
document, change my
mind and revoke or cancel this consent or 
17
obtain or recover custody or
any other rights over such child.  
18
That I have read and understand the
above and I am signing it 
19
as my free and voluntary act.

20
    Dated (insert date).

21
.........................

 

22
    If under Section 8 the consent of more than one person is 
23
required,
then each such person shall execute a separate 
24
consent.

25
    A-1.  (1)   The form of the Final and Irrevocable Consent to 
 


 






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Adoption by a Specified Person or Persons: Non-DCFS Case set 
2
forth in this subsection A-1 is to be used by legal parents 
3
only. This form is not to be used in cases in which there is a 
4
pending petition under Section 2-13 of the Juvenile Court Act 
5
of 1987.
6
    (2)   The form of the Final and Irrevocable Consent to 
7
Adoption by a Specified Person or Persons in a non-DCFS case 
8
shall have the caption of the proceeding in which it is to be 
9
filed and shall be substantially as follows: 
10

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY  
11

A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE  
12
    I, ...., (relationship, e.g., mother, father) of ...., a 
13
..male child, state:
14
    1. That such child was born on .... at ......City ... and 
15
State of....
16
    2. That I reside at ...., County of .... and State of ....
17
    3. That I am of the age of .... years.
18
    4. That I hereby enter my appearance in this proceeding and 
19
waive service of summons on me.
20
    5. That I hereby acknowledge that I have been provided a 
21
copy of the Birth Parent Rights and Responsibilities-Private 
22
Form before signing this Consent and that I have had time to 
23
read, or have had read to me, this Form and that I understand 
24
the Rights and Responsibilities described in this Form. I 
25
understand that if I do not receive any of my rights as 
26
described in said Form, it shall not constitute a basis to 
 


 






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revoke this Final and Irrevocable Consent to Adoption by a 
2
Specified Person. 
3
    6. That I do hereby consent and agree to the adoption of 
4
such child by .... (specified persons) only.
5
    7. That I wish to and understand that upon signing this 
6
consent I do irrevocably and permanently give up all custody 
7
and other parental rights I have to such child if such child is 
8
adopted by .... (specified person or persons).  I hereby 
9
transfer all of my rights to the custody, care and control of 
10
such child to ............................. (specified person 
11
or persons).
12
    8. That I understand such child will be adopted by 
13
....................... (specified person or persons) and that 
14
I cannot under any circumstances, after signing this document, 
15
change my mind and revoke or cancel this consent or obtain or 
16
recover custody or any other rights over such child if 
17
............................ (specified person or persons) 
18
adopt(s) such child; PROVIDED that each specified person has 
19
filed or shall file, within 60 days from the date hereof, a 
20
petition for the adoption of such child.
21
    9.  That if the specified person or persons designated 
22
herein do not file a petition for adoption within the 
23
time-frame specified above, or, if said petition for adoption 
24
is filed within the time-frame specified above but the adoption 
25
petition is dismissed with prejudice or the adoption proceeding 
26
is otherwise concluded without an order declaring the child to 
 


 






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be the adopted child of the specified person or persons, then I 
2
understand that I may request the Court to declare this consent 
3
voidable and return the child to me. I further understand that 
4
the Court will make the final decision of whether or not the 
5
child will be returned to me.
6
    10. That I understand that I must request the return of the 
7
child to me  within 10 business days from the date that written 
8
notice is sent to me.  If I do not make such request within 10 
9
business days of the date of the notice, then I expressly waive 
10
any other notice or service of process in any legal proceeding 
11
for the adoption of the child. 
12
    11. That I expressly acknowledge that nothing in this 
13
Consent
impairs the validity and absolute finality of this

14
Consent under any circumstance other than those described in

15
paragraph 9 of this Consent.
16
    12. That I understand that I have a remaining duty and

17
obligation to keep .............. (insert name and address of 
18
the attorney
for the specified person or persons) informed of 
19
my current
address or other preferred contact information until 
20
this adoption has been finalized. My failure to
do so may 
21
result in the termination of my parental rights and
the child 
22
being placed for adoption in another home.
23
    13. That I do expressly waive any other notice or service 
24
of process in any of the legal proceedings for the adoption of 
25
the child as long as the adoption proceeding by the specified 
26
person or persons is pending.
 


 






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    14. That I have read and understand the above and I am 
2
signing it as my free and voluntary act.
3
    15.  That I acknowledge that this consent is valid even if 
4
the specified person or persons separate or divorce or one of 
5
the specified persons dies prior to the entry of the final 
6
judgment for adoption. 
7
    Dated (insert date). 
8
    ............................................. 
9
    Signature of parent 
10
    .............................................
11
    Address of parent
12
    .............................................
13
    Phone number(s) of parent
14
    .............................................
15
    Personal email(s) of parent 
16
    (3) The form of the certificate of acknowledgement for a 
17
Final and Irrevocable Consent for Adoption by a Specified 
18
Person or Persons: Non-DCFS Case shall be substantially as 
19
follows: 
 
20
STATE OF..............)

21
                      ) SS.

22
COUNTY OF.............)
23
    I, .................... (Name of Judge or other person), 
24
..................... (official title, name, and address), 
25
certify that ............., personally known to me to be the 
 


 






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same person whose name is subscribed to the foregoing Final and 
2
Irrevocable Consent for Adoption by a Specified Person or 
3
Persons; non-DCFS case, appeared before me this day in person 
4
and acknowledged that (she)(he) signed and delivered the 
5
consent as (her)(his) free and voluntary act, for the specified 
6
purpose. I am further satisfied that ........ has read, or has 
7
had read to him or her, the Birth Parents Rights and 
8
Responsibilities-Private Adoption Form. 
9
    A-2. Birth Parent Rights and Responsibilities-Private 
10
Form. The Birth Parent Rights and Responsibilities-Private 
11
Form must be read by, or have been read to, any person 
12
executing a Final and Irrevocable Consent to Adoption under 
13
subsection A, a Final and Irrevocable Consent to Adoption by a 
14
Specified Person or Persons: Non-DCFS Case under subsection 
15
A-1, or a Consent to Adoption of Unborn Child under subsection 
16
B prior to the execution of said Consent. The form of the Birth 
17
Parent Rights and Responsibilities-Private Form shall be 
18
substantially as follows:
19

Birth Parent Rights and Responsibilities-Private Form  
20
    As a birth parent in the State of Illinois, you have the 
21
right:
22
    1. To have your own attorney represent you.  The adoptive 
23
parents may agree to pay for the cost of your attorney in a 
24
manner consistent with Illinois law, but they are not required 
25
to do so.
26
    2. To be treated with dignity and respect at all times and 
 


 






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to make decisions free from coercion and pressure.
2
    3. To receive counseling before and after signing a Final 
3
and Irrevocable Consent to Adoption ("Consent") or a Final and 
4
Irrevocable Consent to Adoption by a Specified Person or 
5
Persons: Non-DCFS Case ("Specified Consent").  The adoptive 
6
parents may agree to pay for the cost of counseling in a manner 
7
consistent with Illinois law, but they are not required to do 
8
so.
9
    4. To ask to be involved in choosing your child's adoptive 
10
parents and to ask to meet them.
11
    5. To ask your child's adoptive parents any questions that 
12
pertain to your decision to place your child with them.
13
    6. To see your child before signing a Consent or Specified 
14
Consent.
15
    7. To request contact with your child and/or the child's 
16
adoptive parents, with the understanding that any promises 
17
regarding contact with your child or receipt of information 
18
about the child after signing a Consent or Specified Consent 
19
cannot be enforced under Illinois law.
20
    8. To receive copies of all documents that you sign and 
21
have those documents provided to you in your preferred 
22
language.
23
    9. To request that your identifying information remain 
24
confidential, unless required otherwise by Illinois law or 
25
court order, and to register with the Illinois Adoption 
26
Registry and Medical Information Exchange.
 


 






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    10. To work with an adoption agency or attorney of your 
2
choice, or change said agency or attorney, provided you 
3
promptly inform all of the parties currently involved.
4
    11. To receive, upon request, a written list of any 
5
promised support, financial or otherwise, from your attorney or 
6
the attorney for your child's adoptive parents.
7
    12. To delay signing a Consent or Specified Consent if you 
8
are not ready to do so.
9
    13. To decline to sign a Consent or Specified Consent even 
10
if you have received financial support from the adoptive 
11
parents.
12
    If you do not receive any of the rights described in this 
13
Form, it shall not be a basis to revoke a Consent or Specified 
14
Consent.
15
    As a Birth Parent in the State of Illinois, you have the 
16
responsibility:
17
    1. To carefully consider your reasons for choosing 
18
adoption.
19
    2. To provide all known medical background and family 
20
information about yourself and your immediate family to your 
21
child's adoptive parents or their attorney.
22
    3. (Birth mothers only) To accurately complete an Affidavit 
23
of Identification, which identifies the father of the child 
24
when known, with the understanding that a birth mother has a 
25
right to decline to identify the birth father.
26
    4. To not accept financial support or reimbursement of 
 


 






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pregnancy related expenses simultaneously from more than one 
2
source.
3
    B. The form of consent required for the adoption of an 
4
unborn child
shall be substantially as follows:

5

CONSENT TO ADOPTION OF UNBORN CHILD


6
    I, ...., state:

7
    That I am the father of a child expected to be born on or 
8
about ....
to .... (name of mother).

9
    That I reside at .... County of ...., and State of .....

10
    That I am of the age of .... years.

11
    That I hereby enter my appearance in such adoption 
12
proceeding and
waive service of summons on me.

13
    That I hereby acknowledge that I have been provided with a 
14
copy of the Birth Parent Rights and Responsibilities-Private 
15
Form before signing this Consent, and that I have had time to 
16
read, or have had read to me, this Form.  I understand that if I 
17
do not receive any of the rights as described in this Form, it 
18
shall not constitute a basis to revoke this Consent To Adoption 
19
Of Unborn Child. 
20
    That I do hereby consent and agree to the adoption of such 
21
child, and
that I have not previously executed a consent or 
22
surrender with respect
to such child.

23
    That I wish to and do understand that by signing this 
24
consent I do
irrevocably and permanently give up all custody 
25
and other parental
rights I have to such child, except that I 
26
have the right to revoke this
consent by giving written notice 
 


 






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of my revocation not later than 72
hours after the birth of the 
2
child.

3
    That I understand such child will be placed for adoption 
4
and that,
except as hereinabove provided, I cannot under any 
5
circumstances, after
signing this document, change my mind and 
6
revoke or cancel this consent
or obtain or recover custody or 
7
any other rights over such child.

8
    That I have read and understand the above and I am signing 
9
it as my
free and voluntary act.

10
    Dated (insert date).

11
........................

12
    B-5. (1) The parent of a child may execute a consent to 
13
standby
adoption by a specified person or persons.  A consent 
14
under this subsection B-5
shall be acknowledged by a parent 
15
pursuant to subsection H and subsection K of
this Section.
The 
16
form of consent required for the standby adoption of a born 
17
child
effective at a future date when the consenting
 parent of 
18
the child dies or
requests that a final judgment of adoption be 
19
entered shall be substantially as
follows:

20

FINAL AND IRREVOCABLE CONSENT


21

TO STANDBY ADOPTION


22
    I, ..., (relationship, e.g. mother or father)
of ...., a 
23
..male child, state:

24
    That the child was born on .... at .....

25
    That I reside at ...., County of ...., and State of .....

26
    That I am of the age of .... years.

 


 






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    That I hereby enter my appearance in this proceeding and 
2
waive service of
summons on me in this action only.

3
    That I do hereby consent and
agree to the standby adoption 
4
of the child, and that I have not previously
executed a consent 
5
or surrender with respect to the child.

6
    That I wish to and understand that by signing this consent 
7
I do irrevocably
and permanently give up all custody and other 
8
parental rights I have to the
child, effective upon
(my death) 
9
(the child's other parent's death) or upon (my) (the other


10
parent's) request for the entry of a final judgment for 
11
adoption if .....
(specified person or persons) adopt my child.

12
    That I understand that until (I die) (the child's other 
13
parent dies), I
retain all legal rights and obligations 
14
concerning the child, but at that time,
I irrevocably give all 
15
custody and other parental rights to .... (specified
person or 
16
persons).

17
    I understand my child will be adopted by ....... (specified 
18
person or
persons) only and that I cannot, under any 
19
circumstances, after signing this
document, change my mind and 
20
revoke or cancel this consent or obtain or recover
custody or 
21
any other rights over my child if ..... (specified person or

22
persons) adopt my child.

23
    I understand that this consent to standby adoption is valid 
24
only if the
petition for standby adoption is filed and that if 
25
....... (specified person or
persons), for any reason, cannot 
26
or will not file a petition for standby
adoption or if his, 
 


 






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her, or their petition for standby adoption is denied, then

2
this consent is void.  I have the right to notice of any other 
3
proceeding that
could affect my parental rights.

4
    That I have read and understand the above and I am signing 
5
it as my free and
voluntary act.

6
    Dated (insert date).

7
....................

 

8
    If under Section 8 the consent of more than one person is 
9
required, then each
such
person shall execute a separate 
10
consent.  A separate consent shall be executed
for each
child.

11
    (2) If the parent consents to a standby adoption by 2 
12
specified persons,
then the form shall contain 2 additional 
13
paragraphs in substantially the
following form:

14
    If .... (specified persons) obtain a judgment of

15
dissolution of
marriage before the judgment for adoption is 
16
entered, then .....
(specified person) shall adopt my child.  I 
17
understand that I cannot change my
mind and revoke this consent 
18
or obtain or recover custody of my child if .....
(specified 
19
persons) obtain a judgment of dissolution of marriage and .....

20
(specified person) adopts my child.  I understand that I cannot 
21
change my
mind and revoke this consent if ...... (specified 
22
persons) obtain a
judgment of dissolution of marriage  before 
23
the adoption is final.  I
understand that this consent to 
24
adoption has no effect on who will get custody
of my child if 
25
..... (specified persons) obtain a judgment of dissolution
of 
 


 






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marriage after the adoption is final.  I understand that if 
2
either .....
(specified persons) dies before the petition to 
3
adopt my child is granted, then
the surviving person may adopt 
4
my child.  I understand that I cannot change my
mind and revoke 
5
this consent or obtain or recover custody of my child if the

6
surviving person adopts my child.

7
    A consent to standby adoption by specified persons on this 
8
form shall have no
effect on a court's determination of custody 
9
or visitation under the Illinois
Marriage and Dissolution
of 
10
Marriage Act if the marriage of the specified persons is 
11
dissolved before
the adoption is final.

12
    (3) The form of the certificate of acknowledgement for a 
13
Final and
Irrevocable Consent for Standby Adoption shall be 
14
substantially as follows:

 
15
STATE OF .....)

16
              ) SS.

17
COUNTY OF ....)

 

18
    I, ....... (name of Judge or other person) ..... (official 
19
title,
name, and address), certify that ......., personally 
20
known to me to be
the same person whose name is subscribed to 
21
the foregoing Final and Irrevocable
Consent to Standby 
22
Adoption, appeared before me this day in person and

23
acknowledged that (she) (he) signed and
delivered the consent 
24
as (her) (his) free and voluntary act, for the specified

 


 






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purpose.

2
    I have fully explained that this consent to adoption is 
3
valid only if the
petition to adopt is filed, and that if the 
4
specified person or persons, for
any reason, cannot or will not 
5
adopt the child or if the adoption petition is
denied, then 
6
this consent will be void.  I have fully explained that if the

7
specified person or persons adopt the child, by signing this 
8
consent (she) (he)
is irrevocably and permanently 
9
relinquishing all parental rights to the child,
and (she) (he) 
10
has stated that such is (her) (his) intention and desire.

11
    Dated (insert date).

12
    Signature..............................

13
    (4) If a consent to standby adoption is executed in this 
14
form,
the consent shall be valid only if the specified
person 
15
or persons adopt the child.  The consent shall be void if:

16
    (a) the specified person or persons do not file a petition 
17
for standby
adoption of the child; or

18
    (b) a court denies the standby adoption petition.

19
    The parent shall not need to take further action to revoke 
20
the consent if the
standby adoption by the specified person or 
21
persons does not occur,
notwithstanding the provisions of 
22
Section 11 of this Act.

23
    C. The form of surrender to any agency given by a parent of 
24
a born
child who is to be subsequently placed for adoption 
25
shall be
substantially as follows and shall contain such other 
26
facts and
statements as the particular agency shall require.

 


 






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1

FINAL AND IRREVOCABLE SURRENDER


2

FOR PURPOSES OF ADOPTION


3
    I, ....  (relationship, e.g., mother, father, relative, 
4
guardian) of
...., a ..male child, state:

5
    That such child was born on ...., at .....

6
    That I reside at ...., County of ...., and State of .....

7
    That I am of the age of .... years.

8
    That I do hereby surrender and entrust the entire custody 
9
and control
of such child to the ....  (the "Agency"), a 
10
(public) (licensed) child
welfare agency with its principal 
11
office in the City of ...., County of
.... and State of ...., 
12
for the purpose of enabling it to care for and
supervise the 
13
care of such child, to place such child for adoption and
to 
14
consent to the legal adoption of such child.

15
    That I hereby grant to the Agency full power and authority 
16
to place
such child with any person or persons it may in its 
17
sole discretion
select to become the adopting parent or parents 
18
and to consent to the
legal adoption of such child by such 
19
person or persons; and to take any
and all measures which, in 
20
the judgment of the Agency, may be for the
best interests of 
21
such child, including authorizing medical, surgical
and dental 
22
care and treatment including inoculation and anaesthesia for

23
such child.

24
    That I wish to and understand that by signing this 
25
surrender I do
irrevocably and permanently give up all custody 
26
and other parental
rights I have to such child.

 


 






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    That I understand I cannot under any circumstances, after 
2
signing
this surrender, change my mind and revoke or cancel 
3
this surrender or
obtain or recover custody or any other rights 
4
over such child.

5
    That I have read and understand the above and I am signing 
6
it as my
free and voluntary act.

7
    Dated (insert date).

8
........................

9
    C-5. The form of a Final and Irrevocable Designated 
10
Surrender for Purposes of Adoption to any agency given by a 
11
parent of a born child who is to be subsequently placed for 
12
adoption shall be substantially as follows and shall contain 
13
such other facts and statements as the particular agency shall 
14
require: 
15

FINAL AND IRREVOCABLE DESIGNATED SURRENDER  
16

FOR PURPOSES OF ADOPTION  
17
    I, .... (relationship, e.g., mother, father, relative, 
18
guardian) of ...., a ..male child, state:
19
    1.    That such child was born on ...., at .....
20
    2.    That I reside at ...., County of ...., and State of 
21
.....
22
    3.    That I am of the age of .... years.
23
    4.    That I hereby enter my appearance in this proceeding and 
24
waive service of summons on me.
25
    5.    That I do hereby surrender and entrust the entire 
26
custody and control of such child to the .... (the "Agency"), a 
 


 






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(public) (licensed) child welfare agency with its principal 
2
office in the City of ...., County of .... and State of ...., 
3
for the purpose of enabling it to care for and supervise the 
4
care of such child, to place such child for adoption with 
5
............................. (specified person or persons) 
6
and to consent to the legal adoption of such child and to take 
7
any and all measures which, in the judgment of the Agency, may 
8
be for the best interests of such child, including authorizing 
9
medical, surgical and dental care and treatment including 
10
inoculation and anesthesia for such child.
11
    6.   That I wish to and understand that by signing this 
12
surrender I do irrevocably and permanently give up all custody 
13
and other parental rights I have to such child.
14
    7. That if the petition for adoption is not filed by the

15
specified person or persons designated herein or, if the

16
petition for adoption is filed but the adoption petition is

17
dismissed with prejudice or the adoption proceeding is

18
otherwise concluded without an order declaring the child to be

19
the adopted child of each specified person, then I understand 
20
that the Agency will provide notice to me within 10 business 
21
days and that such notice will be directed to me using the 
22
contact information I have provided to the Agency. I understand 
23
that I will have 10 business days from the date that the Agency 
24
sends me its notice to respond, within which time I may choose 
25
to designate other adoptive parent(s). However, I acknowledge 
26
that
the Agency has full power and authority to place the child 
 


 






09600HB6080ham001
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1
for adoption with
any person or persons it may in its sole 
2
discretion select to
become the adopting parent or parents and 
3
to consent to the
legal adoption of the child by such person or 
4
persons.
5
    8.    That I acknowledge that this surrender is valid even if 
6
the specified person or persons separate or divorce or one of 
7
the specified persons dies prior to the entry of the final 
8
judgment for adoption.
9
    9.    That I expressly acknowledge that the above paragraphs 7 
10
and 8 do not impair the validity and absolute finality of this 
11
surrender under any circumstance.
12
    10. That I understand that I have a remaining obligation to 
13
keep the Agency informed of my current contact information 
14
until the adoption of the child has been finalized if I wish to 
15
be notified in the event the adoption by the specified 
16
person(s) cannot proceed. 
17
    11.   That I understand I cannot under any circumstances, 
18
after signing this surrender, change my mind and revoke or 
19
cancel this surrender or obtain or recover custody or any other 
20
rights over such child.
21
    12.   That I have read and understand the above and I am 
22
signing it as my free and voluntary act. 
23
    Dated (insert date). 
24
.............................. 
25
    D. The form of surrender to an agency given by a parent of 
26
an unborn
child who is to be subsequently placed for adoption 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
shall be
substantially as follows and shall contain such other 
2
facts and
statements as the particular agency shall require.

3

SURRENDER OF UNBORN CHILD FOR


4

PURPOSES OF ADOPTION


5
    I, .... (father), state:

6
    That I am the father of a child expected to be born on or 
7
about ....
to .... (name of mother).

8
    That I reside at ...., County of ...., and State of .....

9
    That I am of the age of .... years.

10
    That I do hereby surrender and entrust the entire custody 
11
and control
of such child to the .... (the "Agency"), a 
12
(public) (licensed) child
welfare agency with its principal 
13
office in the City of ...., County of
.... and State of ...., 
14
for the purpose of enabling it to care for and
supervise the 
15
care of such child, to place such child for adoption and
to 
16
consent to the legal adoption of such child, and that I have 
17
not
previously executed a consent or surrender with respect to 
18
such child.

19
    That I hereby grant to the Agency full power and authority 
20
to place
such child with any person or persons it may in its 
21
sole discretion
select to become the adopting parent or parents 
22
and to consent to the
legal adoption of such child by such 
23
person or persons; and to take any
and all measures which, in 
24
the judgment of the Agency, may be for the
best interests of 
25
such child, including authorizing medical, surgical
and dental 
26
care and treatment, including inoculation and anaesthesia for

 


 






09600HB6080ham001
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1
such child.

2
    That I wish to and understand that by signing this 
3
surrender I do
irrevocably and permanently give up all custody 
4
and other parental
rights I have to such child.

5
    That I understand I cannot under any circumstances, after 
6
signing
this surrender, change my mind and revoke or cancel 
7
this surrender or
obtain or recover custody or any other rights 
8
over such child, except
that I have the right to revoke this 
9
surrender by giving written notice
of my revocation not later 
10
than 72 hours after the birth of such child.

11
    That I have read and understand the above and I am signing 
12
it as my
free and voluntary act.

13
    Dated (insert date).

14
........................

15
    E. The form of consent required from the parents for the 
16
adoption of
an adult, when such adult elects to obtain such 
17
consent, shall be
substantially as follows:

18

CONSENT


19
    I, ...., (father) (mother) of ...., an adult, state:

20
    That I reside at ...., County of .... and State of .....

21
    That I do hereby consent and agree to the adoption of such 
22
adult by
.... and .....

23
    Dated (insert date).

24
.........................

25
    F. The form of consent required for the adoption of a child 
26
of the
age of 14 years or upwards, or of an adult, to be given 
 


 






09600HB6080ham001
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1
by such person,
shall be substantially as follows:

2

CONSENT


3
    I, ...., state:

4
    That I reside at ...., County of .... and State of .....  
5
That I am
of the age of .... years.  That I consent and agree to 
6
my adoption by
.... and .....

7
    Dated (insert date).

8
........................

9
    G. The form of consent given by an agency to the adoption 
10
by
specified persons of a child previously surrendered to it 
11
shall set
forth that the agency has the authority to execute 
12
such consent.  The
form of consent given by a guardian of the 
13
person of a child sought to
be adopted, appointed by a court of 
14
competent jurisdiction, shall set
forth the facts of such 
15
appointment and the authority of the guardian to
execute such 
16
consent.

17
    H. A consent (other than that given by an agency, or 
18
guardian of the
person of the child sought to be adopted who 
19
was appointed by a court of
competent jurisdiction) shall be 
20
acknowledged by a parent before a  judge of a  court of competent 
21
jurisdiction  or, except as otherwise provided in
this Act, 
22
before a representative of an  agency, or before a person, other 
23
than the attorney for the prospective adoptive parent or 
24
parents, designated by  a court of competent
jurisdiction.

25
    I. A surrender, or any other document equivalent to a 
26
surrender, by
which a child is surrendered to an agency shall 
 


 






09600HB6080ham001
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1
be acknowledged by the
person signing such surrender, or other 
2
document, before a judge of a court of competent jurisdiction, 
3
or, except as otherwise provided in this Act, before a 
4
representative of an agency, or before a  person designated  by a  
5
court
of competent jurisdiction.

6
    J. The form of the certificate of acknowledgment for a 
7
consent, a
surrender, or any other document equivalent to a 
8
surrender, shall be
substantially as follows:

9
STATE OF ....)

10
             ) SS.

11
COUNTY OF ...)

12
    I, .... (Name of judge or other person), .... (official 
13
title, name and
location of court or status or position of 
14
other person),
certify that ...., personally known to me to be 
15
the same person whose
name is subscribed to the foregoing 
16
(consent) (surrender), appeared
before me this day in person 
17
and acknowledged that (she) (he) signed and
delivered such 
18
(consent) (surrender) as (her) (his) free and voluntary
act, 
19
for the specified purpose.

20
    I have fully explained that by signing such (consent) 
21
(surrender)
(she) (he) is irrevocably relinquishing all 
22
parental rights to such
child or adult and (she) (he) has 
23
stated that such is (her) (his)
intention and desire. (Add if 
24
Consent only) I am further satisfied that ........ has read, or 
25
has had read to him or her, the Birth Parents Rights and 
26
Responsibilities-Private Adoption Form.

 


 






09600HB6080ham001
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1
    Dated (insert date).

2
    Signature ...............

3
    K. When the execution of a consent or a surrender is 
4
acknowledged
before someone other than a judge,
such other 
5
person shall have his or her signature on the certificate

6
acknowledged before a notary public, in form substantially as 
7
follows:

8
STATE OF ....)

9
             ) SS.

10
COUNTY OF ...)

11
    I, a Notary Public, in and for the County of ......, in the 
12
State of
......, certify that ...., personally known to me to 
13
be the
same person whose name is subscribed to the foregoing 
14
certificate of
acknowledgment, appeared before me in person and 
15
acknowledged that (she)
(he) signed such certificate as (her) 
16
(his) free and voluntary act and
that the statements made in 
17
the certificate are true.

18
    Dated (insert date).

19
    
Signature ...................... Notary Public


20

(official seal)


 

21
    There shall be attached a certificate of magistracy, or 
22
other
comparable proof of office of the notary public 
23
satisfactory to the
court, to a consent signed and acknowledged 
24
in another state.

25
    L. A surrender or consent executed and acknowledged outside 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
of this
State, either in accordance with the law of this State 
2
or in accordance
with the law of the place where executed, is 
3
valid.

4
    M. Where a consent or a surrender is signed in a foreign 
5
country,
the execution of such consent shall be acknowledged or 
6
affirmed in a
manner conformable to the law and procedure of 
7
such country.

8
    N. If the person signing a consent or surrender is in the 
9
military
service of the United States, the execution of such 
10
consent or surrender
may be acknowledged before a commissioned 
11
officer and the signature of
such officer on such certificate 
12
shall be verified or acknowledged
before a notary public or by 
13
such other procedure as is then in effect
for such division or 
14
branch of the armed forces.

15
    O. (1) The parent or parents of a child in whose interests 
16
a petition
under Section 2-13 of the Juvenile Court Act of 1987 
17
is pending may, with the
approval of the designated 
18
representative of the Department of Children and
Family 
19
Services, execute a consent to adoption by a specified person 
20
or
persons:


21
        (a) in whose physical custody the child has resided for 
22
    at least 6
months;
or


23
        (b) in whose physical custody at least one sibling of 
24
    the child who is the
subject of this consent has resided 
25
    for at least 6 months, and
the child who is
the subject of 
26
    this consent is currently residing in this foster home; or


 


 






09600HB6080ham001
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1
        (c) in whose physical custody a child under one year of 
2
    age has resided
for at least 3 months.

3
A consent under this subsection O shall be acknowledged by a 
4
parent pursuant to
subsection H and subsection K of this 
5
Section.

6
    (2) The consent to adoption by a specified person or 
7
persons shall have the
caption of the proceeding in which it is 
8
to be filed and shall be substantially
as follows:

9

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY


10

A SPECIFIED PERSON OR PERSONS : DCFS CASE  


11
    I, ......................................, the 
12
.................. (mother or
father) of a ....male child, 
13
state:


14
        1. My child ............................ (name of 
15
    child) was born on
(insert date) at .................... 
16
    Hospital in
................ County, State of 
17
    ...............


18
        2. I reside at ......................, County of 
19
    ............. and
State of ..............


20
        3. I, ..........................., am .... years old.


21
        4. I enter my appearance in this action to adopt my 
22
    child by the
person or persons specified herein by me and 
23
    waive service of
summons on me in this action only.


24
        5. I consent to the adoption of my child by

25
    .............................
(specified person or 
26
    persons) only.


 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
        6. I wish to sign this consent and I understand that by 
2
    signing this
consent I irrevocably and permanently give up 
3
    all parental rights I have to my
child if my child is 
4
    adopted by ............................. (specified person

5
    or persons).


6
        7. I understand my child will be adopted by 
7
    .............................
(specified person or 
8
    persons) only and that I cannot under any circumstances,

9
    after signing this document, change my mind and revoke or 
10
    cancel this consent
or obtain or recover custody or any 
11
    other rights over my child if
............................ 
12
    (specified person or persons) adopt my child.


13
        8. I understand that this consent to adoption is valid 
14
    only if the
petition to adopt is filed within one year from 
15
    the date that I sign it and
that if ....................... 
16
    (specified person or persons), for any reason,
cannot or 
17
    will not file a petition to adopt my child within that one 
18
    year
period or if their adoption petition is denied, then 
19
    this consent will be
voidable after one year upon the 
20
    timely filing of my motion.  If I file this
motion before 
21
    the filing of the petition for adoption, I understand that 
22
    the
court shall revoke this specific consent.
I have the 
23
    right to notice of any other proceeding that could affect 
24
    my
parental rights, except for the proceeding for 
25
    ............. (specified person
or persons) to adopt my 
26
    child.


 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
        9. I have read and understand the above and I am 
2
    signing it as my free
and voluntary act.

3
        Dated (insert date).

4
        .............................................

5
        Signature of parent

6
    (3) If the parent consents to an adoption by 2 specified 
7
persons, then the
form shall contain 2 additional paragraphs in 
8
substantially the following form:


9
        10. If ............... (specified persons) get a 
10
    divorce
before the petition to adopt my child is granted, 
11
    then ..........
(specified person) shall adopt my child.  I 
12
    understand that I
cannot change my mind and revoke this 
13
    consent or obtain or
recover custody over my child if 
14
    ............. (specified persons)
divorce and 
15
    ............. (specified person) adopts my
child.  I 
16
    understand that I cannot change my mind and revoke
this 
17
    consent or obtain or recover custody over my child if

18
    ................. (specified persons) divorce after the

19
    adoption is final.  I understand that this consent to 
20
    adoption
has no effect on who will get custody of my child 
21
    if they
divorce after the adoption is final.


22
        11. I understand that if either ...............

23
    (specified persons) dies before the petition to adopt
my 
24
    child is granted, then the surviving person can adopt my 
25
    child.  I
understand that I cannot change my mind and revoke 
26
    this consent
or obtain or recover custody over my child if 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
    the surviving
person adopts my child.

2
    A consent to adoption by specified persons on this form 
3
shall
have no effect on a court's determination of custody or 
4
visitation
under the Illinois Marriage and Dissolution of 
5
Marriage Act if the
marriage of the
specified persons is 
6
dissolved after the adoption is final.

7
    (4) The form of the certificate of acknowledgement for a 
8
Final and
Irrevocable Consent for Adoption by a Specified 
9
Person or Persons shall be
substantially as follows:

 
10
STATE OF..............)

11
                      ) SS.

12
COUNTY OF.............)

 

13
    I, .................... (Name of Judge or other person),

14
..................... (official title, name, and address),

15
certify that ............., personally known to me to be the 
16
same person whose
name is subscribed to the foregoing Final and 
17
Irrevocable Consent for Adoption
by a Specified Person or 
18
Persons, appeared before me this day
in person and acknowledged 
19
that (she)(he) signed and delivered the consent as
(her)(his) 
20
free and voluntary act, for the specified purpose.

21
    I have fully explained that this consent to adoption is 
22
valid only if the
petition to adopt is filed within one year 
23
from the date that it is signed, and
that if the specified 
24
person or persons, for any reason, cannot or will not
adopt the 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
child or if the adoption petition is denied, then this consent 
2
will
be voidable after one year upon the timely filing of a 
3
motion by the parent
to revoke the consent. I explained that if 
4
this motion is filed before the
filing of the petition for 
5
adoption, the court shall revoke this specific
consent.  I have 
6
fully explained that if the specified person or
persons adopt

7
the child, by signing this consent this parent is irrevocably

8
and permanently
relinquishing all parental rights to the child, 
9
and this parent has stated that
such is (her)(his) intention 
10
and desire.

11
    Dated (insert date).

12
    ...............................

13
    Signature

14
    (5) If a consent to adoption by a specified person or 
15
persons is executed in
this form, the following provisions 
16
shall apply.  The consent shall be valid
only if that specified 
17
person or persons adopt the child.  The consent shall be

18
voidable after one year if:


19
        (a) the specified person or persons do not file a 
20
    petition to adopt the
child within one year after the 
21
    consent is signed and the parent files a
timely motion to 
22
    revoke this consent.  If this motion is filed before the

23
    filing of the petition for adoption the court shall revoke 
24
    this consent; or


25
        (b) a court denies the adoption petition; or


26
        (c) the Department of Children and Family Services 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
    Guardianship
Administrator determines that the specified 
2
    person or persons will not or
cannot complete the adoption, 
3
    or in the best interests of the child should not
adopt the 
4
    child.

5
    Within 30 days of the consent becoming void, the Department 
6
of Children and
Family Services Guardianship Administrator 
7
shall make good faith attempts to
notify the parent in writing 
8
and shall give written notice to the court and all
additional 
9
parties in writing that the adoption has not occurred or will 
10
not
occur and that the consent is void.  If the adoption by a 
11
specified person or
persons does not occur, no proceeding for 
12
termination of parental rights shall
be brought unless the 
13
biological parent who executed the consent to adoption by
a 
14
specified person or persons has been notified of the proceeding 
15
pursuant to
Section 7 of this Act or subsection (4) of Section 
16
2-13 of the Juvenile Court
Act of 1987.  The parent shall not 
17
need to take further action to revoke the
consent if the 
18
specified adoption does not occur, notwithstanding the

19
provisions of Section 11 of this Act.

20
    (6) The Department of Children and Family Services is 
21
authorized
to promulgate rules necessary to implement this 
22
subsection O.

23
    (7) The Department shall collect and maintain data 
24
concerning the efficacy
of specific consents.  This data shall 
25
include the number of specific consents
executed and their 
26
outcomes, including but not limited to the number of
children 
 


 






09600HB6080ham001
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LRB096 18717 AJO 38110 a




1
adopted pursuant to the consents, the number of children for 
2
whom
adoptions are not completed, and the reason or reasons why 
3
the adoptions are
not completed.

4
    P. If the person signing a consent is incarcerated or 
5
detained in a correctional facility, prison, jail, detention 
6
center, or other comparable institution, either in this State 
7
or any other jurisdiction, the execution of such consent may be 
8
acknowledged before social service personnel of such 
9
institution, or before a person designated by a court of 
10
competent jurisdiction.
11
    Q. A consent may be acknowledged telephonically, via 
12
audiovisual connection, or other electronic means, provided 
13
that a court of competent jurisdiction has entered an order 
14
approving the execution of the consent in such manner and has 
15
designated an individual to be physically present with the 
16
parent executing such consent in order to verify the identity 
17
of the parent.
18
    R. An agency whose representative is acknowledging a 
19
consent pursuant to this Section shall be a public child 
20
welfare agency, or a child welfare agency, or a child placing 
21
agency that is authorized or licensed in the State or 
22
jurisdiction in which the consent is signed. 
23
(Source: P.A. 96-601, eff. 8-21-09.)

 
 
24
    Section 99. Effective date. This Act takes effect on 
25
January 1, 2011.".