Rep. Sara Feigenholtz
Filed: 3/17/2010
 
 

 




 

 		












09600HB6080ham002

LRB096 18717 AJO 38854 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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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, before signing this 
7
Consent, ........ has read, or has had read to him or her, the 
8
Birth Parent Rights and Responsibilities-Private 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 prospective 
23
adoptive parents may agree to pay for the cost of your attorney 
24
in a manner consistent with Illinois law, but they are not 
25
required 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"), a Final and 
4
Irrevocable Consent to Adoption by a Specified Person or 
5
Persons: Non-DCFS Case ("Specified Consent"), or a Consent to 
6
Adoption of Unborn Child ("Unborn Consent").  The prospective 
7
adoptive parents may agree to pay for the cost of counseling in 
8
a manner consistent with Illinois law, but they are not 
9
required to do so.
10
    4. To ask to be involved in choosing your child's 
11
prospective adoptive parents and to ask to meet them.
12
    5. To ask your child's prospective adoptive parents any 
13
questions that pertain to your decision to place your child 
14
with them.
15
    6. To see your child before signing a Consent or Specified 
16
Consent.
17
    7. To request contact with your child and/or the child's 
18
prospective adoptive parents, with the understanding that any 
19
promises regarding contact with your child or receipt of 
20
information about the child after signing a Consent, Specified 
21
Consent, or Unborn Consent cannot be enforced under Illinois 
22
law.
23
    8. To receive copies of all documents that you sign and 
24
have those documents provided to you in your preferred 
25
language.
26
    9. To request that your identifying information remain 
 


 






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


 






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when known, with the understanding that a birth mother has a 
2
right to decline to identify the birth father.
3
    4. To not accept financial support or reimbursement of 
4
pregnancy related expenses simultaneously from more than one 
5
source.
6
    B. The form of consent required for the adoption of an 
7
unborn child
shall be substantially as follows:

8

CONSENT TO ADOPTION OF UNBORN CHILD


9
    I, ...., state:

10
    That I am the father of a child expected to be born on or 
11
about ....
to .... (name of mother).

12
    That I reside at .... County of ...., and State of .....

13
    That I am of the age of .... years.

14
    That I hereby enter my appearance in such adoption 
15
proceeding and
waive service of summons on me.

16
    That I hereby acknowledge that I have been provided with a 
17
copy of the Birth Parent Rights and Responsibilities-Private 
18
Form before signing this Consent, and that I have had time to 
19
read, or have had read to me, this Form.  I understand that if I 
20
do not receive any of the rights as described in this Form, it 
21
shall not constitute a basis to revoke this Consent to Adoption 
22
of Unborn Child. 
23
    That I do hereby consent and agree to the adoption of such 
24
child, and
that I have not previously executed a consent or 
25
surrender with respect
to such child.

26
    That I wish to and do understand that by signing this 
 


 






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consent I do
irrevocably and permanently give up all custody 
2
and other parental
rights I have to such child, except that I 
3
have the right to revoke this
consent by giving written notice 
4
of my revocation not later than 72
hours after the birth of the 
5
child.

6
    That I understand such child will be placed for adoption 
7
and that,
except as hereinabove provided, I cannot under any 
8
circumstances, after
signing this document, change my mind and 
9
revoke or cancel this consent
or obtain or recover custody or 
10
any other rights over 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
    B-5. (1) The parent of a child may execute a consent to 
16
standby
adoption by a specified person or persons.  A consent 
17
under this subsection B-5
shall be acknowledged by a parent 
18
pursuant to subsection H and subsection K of
this Section.
The 
19
form of consent required for the standby adoption of a born 
20
child
effective at a future date when the consenting
 parent of 
21
the child dies or
requests that a final judgment of adoption be 
22
entered shall be substantially as
follows:

23

FINAL AND IRREVOCABLE CONSENT


24

TO STANDBY ADOPTION


25
    I, ..., (relationship, e.g. mother or father)
of ...., a 
26
..male child, state:

 


 






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

2
    That I reside at ...., County of ...., and State of .....

3
    That I am of the age of .... years.

4
    That I hereby enter my appearance in this proceeding and 
5
waive service of
summons on me in this action only.

6
    That I do hereby consent and
agree to the standby adoption 
7
of the child, and that I have not previously
executed a consent 
8
or surrender with respect to the child.

9
    That I wish to and understand that by signing this consent 
10
I do irrevocably
and permanently give up all custody and other 
11
parental rights I have to the
child, effective upon
(my death) 
12
(the child's other parent's death) or upon (my) (the other


13
parent's) request for the entry of a final judgment for 
14
adoption if .....
(specified person or persons) adopt my child.

15
    That I understand that until (I die) (the child's other 
16
parent dies), I
retain all legal rights and obligations 
17
concerning the child, but at that time,
I irrevocably give all 
18
custody and other parental rights to .... (specified
person or 
19
persons).

20
    I understand my child will be adopted by ....... (specified 
21
person or
persons) only and that I cannot, under any 
22
circumstances, after signing this
document, change my mind and 
23
revoke or cancel this consent or obtain or recover
custody or 
24
any other rights over my child if ..... (specified person or

25
persons) adopt my child.

26
    I understand that this consent to standby adoption is valid 
 


 






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only if the
petition for standby adoption is filed and that if 
2
....... (specified person or
persons), for any reason, cannot 
3
or will not file a petition for standby
adoption or if his, 
4
her, or their petition for standby adoption is denied, then

5
this consent is void.  I have the right to notice of any other 
6
proceeding that
could affect my parental rights.

7
    That I have read and understand the above and I am signing 
8
it as my free and
voluntary act.

9
    Dated (insert date).

10
....................

 

11
    If under Section 8 the consent of more than one person is 
12
required, then each
such
person shall execute a separate 
13
consent.  A separate consent shall be executed
for each
child.

14
    (2) If the parent consents to a standby adoption by 2 
15
specified persons,
then the form shall contain 2 additional 
16
paragraphs in substantially the
following form:

17
    If .... (specified persons) obtain a judgment of

18
dissolution of
marriage before the judgment for adoption is 
19
entered, then .....
(specified person) shall adopt my child.  I 
20
understand that I cannot change my
mind and revoke this consent 
21
or obtain or recover custody of my child if .....
(specified 
22
persons) obtain a judgment of dissolution of marriage and .....

23
(specified person) adopts my child.  I understand that I cannot 
24
change my
mind and revoke this consent if ...... (specified 
25
persons) obtain a
judgment of dissolution of marriage  before 
 


 






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the adoption is final.  I
understand that this consent to 
2
adoption has no effect on who will get custody
of my child if 
3
..... (specified persons) obtain a judgment of dissolution
of 
4
marriage after the adoption is final.  I understand that if 
5
either .....
(specified persons) dies before the petition to 
6
adopt my child is granted, then
the surviving person may adopt 
7
my child.  I understand that I cannot change my
mind and revoke 
8
this consent or obtain or recover custody of my child if the

9
surviving person adopts my child.

10
    A consent to standby adoption by specified persons on this 
11
form shall have no
effect on a court's determination of custody 
12
or visitation under the Illinois
Marriage and Dissolution
of 
13
Marriage Act if the marriage of the specified persons is 
14
dissolved before
the adoption is final.

15
    (3) The form of the certificate of acknowledgement for a 
16
Final and
Irrevocable Consent for Standby Adoption shall be 
17
substantially as follows:

 
18
STATE OF .....)

19
              ) SS.

20
COUNTY OF ....)

 

21
    I, ....... (name of Judge or other person) ..... (official 
22
title,
name, and address), certify that ......., personally 
23
known to me to be
the same person whose name is subscribed to 
24
the foregoing Final and Irrevocable
Consent to Standby 
 


 






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Adoption, appeared before me this day in person and

2
acknowledged that (she) (he) signed and
delivered the consent 
3
as (her) (his) free and voluntary act, for the specified

4
purpose.

5
    I have fully explained that this consent to adoption is 
6
valid only if the
petition to adopt is filed, and that if the 
7
specified person or persons, for
any reason, cannot or will not 
8
adopt the child or if the adoption petition is
denied, then 
9
this consent will be void.  I have fully explained that if the

10
specified person or persons adopt the child, by signing this 
11
consent (she) (he)
is irrevocably and permanently 
12
relinquishing all parental rights to the child,
and (she) (he) 
13
has stated that such is (her) (his) intention and desire.

14
    Dated (insert date).

15
    Signature..............................

16
    (4) If a consent to standby adoption is executed in this 
17
form,
the consent shall be valid only if the specified
person 
18
or persons adopt the child.  The consent shall be void if:

19
    (a) the specified person or persons do not file a petition 
20
for standby
adoption of the child; or

21
    (b) a court denies the standby adoption petition.

22
    The parent shall not need to take further action to revoke 
23
the consent if the
standby adoption by the specified person or 
24
persons does not occur,
notwithstanding the provisions of 
25
Section 11 of this Act.

26
    C. The form of surrender to any agency given by a parent of 
 


 






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a born
child who is to be subsequently placed for adoption 
2
shall be
substantially as follows and shall contain such other 
3
facts and
statements as the particular agency shall require.

4

FINAL AND IRREVOCABLE SURRENDER


5

FOR PURPOSES OF ADOPTION


6
    I, ....  (relationship, e.g., mother, father, relative, 
7
guardian) of
...., a ..male child, state:

8
    That such child was born on ...., at .....

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

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

11
    That I do hereby surrender and entrust the entire custody 
12
and control
of such child to the ....  (the "Agency"), a 
13
(public) (licensed) child
welfare agency with its principal 
14
office in the City of ...., County of
.... and State of ...., 
15
for the purpose of enabling it to care for and
supervise the 
16
care of such child, to place such child for adoption and
to 
17
consent to the legal adoption of such child.

18
    That I hereby grant to the Agency full power and authority 
19
to place
such child with any person or persons it may in its 
20
sole discretion
select to become the adopting parent or parents 
21
and to consent to the
legal adoption of such child by such 
22
person or persons; and to take any
and all measures which, in 
23
the judgment of the Agency, may be for the
best interests of 
24
such child, including authorizing medical, surgical
and dental 
25
care and treatment including inoculation and anaesthesia for

26
such child.

 


 






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

4
    That I understand I cannot under any circumstances, after 
5
signing
this surrender, change my mind and revoke or cancel 
6
this surrender or
obtain or recover custody or any other rights 
7
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
    C-5. The form of a Final and Irrevocable Designated 
13
Surrender for Purposes of Adoption to any agency given by a 
14
parent of a born child who is to be subsequently placed for 
15
adoption shall be substantially as follows and shall contain 
16
such other facts and statements as the particular agency shall 
17
require: 
18

FINAL AND IRREVOCABLE DESIGNATED SURRENDER  
19

FOR PURPOSES OF ADOPTION  
20
    I, .... (relationship, e.g., mother, father, relative, 
21
guardian) of ...., a ..male child, state:
22
    1.    That such child was born on ...., at .....
23
    2.    That I reside at ...., County of ...., and State of 
24
.....
25
    3.    That I am of the age of .... years.
26
    4.    That I do hereby surrender and entrust the entire 
 


 






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custody and control of such child to the .... (the "Agency"), a 
2
(public) (licensed) child welfare agency with its principal 
3
office in the City of ...., County of .... and State of ...., 
4
for the purpose of enabling it to care for and supervise the 
5
care of such child, to place such child for adoption with 
6
............................. (specified person or persons) 
7
and to consent to the legal adoption of such child and to take 
8
any and all measures which, in the judgment of the Agency, may 
9
be for the best interests of such child, including authorizing 
10
medical, surgical and dental care and treatment including 
11
inoculation and anesthesia for such child.
12
    5.   That I wish to and understand that by signing this 
13
surrender I do irrevocably and permanently give up all custody 
14
and other parental rights I have to such child.
15
    6. That if the petition for adoption is not filed by the

16
specified person or persons designated herein or, if the

17
petition for adoption is filed but the adoption petition is

18
dismissed with prejudice or the adoption proceeding is

19
otherwise concluded without an order declaring the child to be

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


 






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


 






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1
an unborn
child who is to be subsequently placed for adoption 
2
shall be
substantially as follows and shall contain such other 
3
facts and
statements as the particular agency shall require.

4

SURRENDER OF UNBORN CHILD FOR


5

PURPOSES OF ADOPTION


6
    I, .... (father), 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 do hereby surrender and entrust the entire custody 
12
and control
of such child to the .... (the "Agency"), a 
13
(public) (licensed) child
welfare agency with its principal 
14
office in the City of ...., County of
.... and State of ...., 
15
for the purpose of enabling it to care for and
supervise the 
16
care of such child, to place such child for adoption and
to 
17
consent to the legal adoption of such child, and that I have 
18
not
previously executed a consent or surrender with respect to 
19
such child.

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


 






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1
care and treatment, including inoculation and anaesthesia for

2
such child.

3
    That I wish to and understand that by signing this 
4
surrender I do
irrevocably and permanently give up all custody 
5
and other parental
rights I have to such child.

6
    That I understand I cannot under any circumstances, after 
7
signing
this surrender, change my mind and revoke or cancel 
8
this surrender or
obtain or recover custody or any other rights 
9
over such child, except
that I have the right to revoke this 
10
surrender by giving written notice
of my revocation not later 
11
than 72 hours after the birth of such child.

12
    That I have read and understand the above and I am signing 
13
it as my
free and voluntary act.

14
    Dated (insert date).

15
........................

16
    E. The form of consent required from the parents for the 
17
adoption of
an adult, when such adult elects to obtain such 
18
consent, shall be
substantially as follows:

19

CONSENT


20
    I, ...., (father) (mother) of ...., an adult, state:

21
    That I reside at ...., County of .... and State of .....

22
    That I do hereby consent and agree to the adoption of such 
23
adult by
.... and .....

24
    Dated (insert date).

25
.........................

26
    F. The form of consent required for the adoption of a child 
 


 






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1
of the
age of 14 years or upwards, or of an adult, to be given 
2
by such person,
shall be substantially as follows:

3

CONSENT


4
    I, ...., state:

5
    That I reside at ...., County of .... and State of .....  
6
That I am
of the age of .... years.  That I consent and agree to 
7
my adoption by
.... and .....

8
    Dated (insert date).

9
........................

10
    G. The form of consent given by an agency to the adoption 
11
by
specified persons of a child previously surrendered to it 
12
shall set
forth that the agency has the authority to execute 
13
such consent.  The
form of consent given by a guardian of the 
14
person of a child sought to
be adopted, appointed by a court of 
15
competent jurisdiction, shall set
forth the facts of such 
16
appointment and the authority of the guardian to
execute such 
17
consent.

18
    H. A consent (other than that given by an agency, or 
19
guardian of the
person of the child sought to be adopted who 
20
was appointed by a court of
competent jurisdiction) shall be 
21
acknowledged by a parent before a  judge of a  court of competent 
22
jurisdiction  or, except as otherwise provided in
this Act, 
23
before a representative of an  agency, or before a person, other 
24
than the attorney for the prospective adoptive parent or 
25
parents, designated by  a court of competent
jurisdiction.

26
    I. A surrender, or any other document equivalent to a 
 


 






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1
surrender, by
which a child is surrendered to an agency shall 
2
be acknowledged by the
person signing such surrender, or other 
3
document, before a judge of a court of competent jurisdiction, 
4
or, except as otherwise provided in this Act, before a 
5
representative of an agency, or before a  person designated  by a  
6
court
of competent jurisdiction.

7
    J. The form of the certificate of acknowledgment for a 
8
consent, a
surrender, or any other document equivalent to a 
9
surrender, shall be
substantially as follows:

10
STATE OF ....)

11
             ) SS.

12
COUNTY OF ...)

13
    I, .... (Name of judge or other person), .... (official 
14
title, name and
location of court or status or position of 
15
other person),
certify that ...., personally known to me to be 
16
the same person whose
name is subscribed to the foregoing 
17
(consent) (surrender), appeared
before me this day in person 
18
and acknowledged that (she) (he) signed and
delivered such 
19
(consent) (surrender) as (her) (his) free and voluntary
act, 
20
for the specified purpose.

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


 






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1
Birth Parent Rights and Responsibilities-Private Form.

2
    Dated (insert date).

3
    Signature ...............

4
    K. When the execution of a consent or a surrender is 
5
acknowledged
before someone other than a judge,
such other 
6
person shall have his or her signature on the certificate

7
acknowledged before a notary public, in form substantially as 
8
follows:

9
STATE OF ....)

10
             ) SS.

11
COUNTY OF ...)

12
    I, a Notary Public, in and for the County of ......, in the 
13
State of
......, certify that ...., personally known to me to 
14
be the
same person whose name is subscribed to the foregoing 
15
certificate of
acknowledgment, appeared before me in person and 
16
acknowledged that (she)
(he) signed such certificate as (her) 
17
(his) free and voluntary act and
that the statements made in 
18
the certificate are true.

19
    Dated (insert date).

20
    
Signature ...................... Notary Public


21

(official seal)


 

22
    There shall be attached a certificate of magistracy, or 
23
other
comparable proof of office of the notary public 
24
satisfactory to the
court, to a consent signed and acknowledged 
25
in another state.

 


 






09600HB6080ham002
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1
    L. A surrender or consent executed and acknowledged outside 
2
of this
State, either in accordance with the law of this State 
3
or in accordance
with the law of the place where executed, is 
4
valid.

5
    M. Where a consent or a surrender is signed in a foreign 
6
country,
the execution of such consent shall be acknowledged or 
7
affirmed in a
manner conformable to the law and procedure of 
8
such country.

9
    N. If the person signing a consent or surrender is in the 
10
military
service of the United States, the execution of such 
11
consent or surrender
may be acknowledged before a commissioned 
12
officer and the signature of
such officer on such certificate 
13
shall be verified or acknowledged
before a notary public or by 
14
such other procedure as is then in effect
for such division or 
15
branch of the armed forces.

16
    O. (1) The parent or parents of a child in whose interests 
17
a petition
under Section 2-13 of the Juvenile Court Act of 1987 
18
is pending may, with the
approval of the designated 
19
representative of the Department of Children and
Family 
20
Services, execute a consent to adoption by a specified person 
21
or
persons:


22
        (a) in whose physical custody the child has resided for 
23
    at least 6
months;
or


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


 






09600HB6080ham002
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1
    this consent is currently residing in this foster home; or


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

4
A consent under this subsection O shall be acknowledged by a 
5
parent pursuant to
subsection H and subsection K of this 
6
Section.

7
    (2) The consent to adoption by a specified person or 
8
persons shall have the
caption of the proceeding in which it is 
9
to be filed and shall be substantially
as follows:

10

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY


11

A SPECIFIED PERSON OR PERSONS : DCFS CASE  


12
    I, ......................................, the 
13
.................. (mother or
father) of a ....male child, 
14
state:


15
        1. My child ............................ (name of 
16
    child) was born on
(insert date) at .................... 
17
    Hospital in
................ County, State of 
18
    ...............


19
        2. I reside at ......................, County of 
20
    ............. and
State of ..............


21
        3. I, ..........................., am .... years old.


22
        4. I enter my appearance in this action to adopt my 
23
    child by the
person or persons specified herein by me and 
24
    waive service of
summons on me in this action only.


25
        5. I consent to the adoption of my child by

26
    .............................
(specified person or 
 


 






09600HB6080ham002
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1
    persons) only.


2
        6. I wish to sign this consent and I understand that by 
3
    signing this
consent I irrevocably and permanently give up 
4
    all parental rights I have to my
child if my child is 
5
    adopted by ............................. (specified person

6
    or persons).


7
        7. I understand my child will be adopted by 
8
    .............................
(specified person or 
9
    persons) only and that I cannot under any circumstances,

10
    after signing this document, change my mind and revoke or 
11
    cancel this consent
or obtain or recover custody or any 
12
    other rights over my child if
............................ 
13
    (specified person or persons) adopt my child.


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


 






09600HB6080ham002
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LRB096 18717 AJO 38854 a




1
    child.


2
        9. I have read and understand the above and I am 
3
    signing it as my free
and voluntary act.

4
        Dated (insert date).

5
        .............................................

6
        Signature of parent

7
    (3) If the parent consents to an adoption by 2 specified 
8
persons, then the
form shall contain 2 additional paragraphs in 
9
substantially the following form:


10
        10. If ............... (specified persons) get a 
11
    divorce
before the petition to adopt my child is granted, 
12
    then ..........
(specified person) shall adopt my child.  I 
13
    understand that I
cannot change my mind and revoke this 
14
    consent or obtain or
recover custody over my child if 
15
    ............. (specified persons)
divorce and 
16
    ............. (specified person) adopts my
child.  I 
17
    understand that I cannot change my mind and revoke
this 
18
    consent or obtain or recover custody over my child if

19
    ................. (specified persons) divorce after the

20
    adoption is final.  I understand that this consent to 
21
    adoption
has no effect on who will get custody of my child 
22
    if they
divorce after the adoption is final.


23
        11. I understand that if either ...............

24
    (specified persons) dies before the petition to adopt
my 
25
    child is granted, then the surviving person can adopt my 
26
    child.  I
understand that I cannot change my mind and revoke 
 


 






09600HB6080ham002
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LRB096 18717 AJO 38854 a




1
    this consent
or obtain or recover custody over my child if 
2
    the surviving
person adopts my child.

3
    A consent to adoption by specified persons on this form 
4
shall
have no effect on a court's determination of custody or 
5
visitation
under the Illinois Marriage and Dissolution of 
6
Marriage Act if the
marriage of the
specified persons is 
7
dissolved after the adoption is final.

8
    (4) The form of the certificate of acknowledgement for a 
9
Final and
Irrevocable Consent for Adoption by a Specified 
10
Person or Persons: DCFS Case shall be
substantially as follows:

 
11
STATE OF..............)

12
                      ) SS.

13
COUNTY OF.............)

 

14
    I, .................... (Name of Judge or other person),

15
..................... (official title, name, and address),

16
certify that ............., personally known to me to be the 
17
same person whose
name is subscribed to the foregoing Final and 
18
Irrevocable Consent for Adoption
by a Specified Person or 
19
Persons, appeared before me this day
in person and acknowledged 
20
that (she)(he) signed and delivered the consent as
(her)(his) 
21
free and voluntary act, for the specified purpose.

22
    I have fully explained that this consent to adoption is 
23
valid only if the
petition to adopt is filed within one year 
24
from the date that it is signed, and
that if the specified 
 


 






09600HB6080ham002
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1
person or persons, for any reason, cannot or will not
adopt the 
2
child or if the adoption petition is denied, then this consent 
3
will
be voidable after one year upon the timely filing of a 
4
motion by the parent
to revoke the consent. I explained that if 
5
this motion is filed before the
filing of the petition for 
6
adoption, the court shall revoke this specific
consent.  I have 
7
fully explained that if the specified person or
persons adopt

8
the child, by signing this consent this parent is irrevocably

9
and permanently
relinquishing all parental rights to the child, 
10
and this parent has stated that
such is (her)(his) intention 
11
and desire.

12
    Dated (insert date).

13
    ...............................

14
    Signature

15
    (5) If a consent to adoption by a specified person or 
16
persons is executed in
this form, the following provisions 
17
shall apply.  The consent shall be valid
only if that specified 
18
person or persons adopt the child.  The consent shall be

19
voidable after one year if:


20
        (a) the specified person or persons do not file a 
21
    petition to adopt the
child within one year after the 
22
    consent is signed and the parent files a
timely motion to 
23
    revoke this consent.  If this motion is filed before the

24
    filing of the petition for adoption the court shall revoke 
25
    this consent; or


26
        (b) a court denies the adoption petition; or


 


 






09600HB6080ham002
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1
        (c) the Department of Children and Family Services 
2
    Guardianship
Administrator determines that the specified 
3
    person or persons will not or
cannot complete the adoption, 
4
    or in the best interests of the child should not
adopt the 
5
    child.

6
    Within 30 days of the consent becoming void, the Department 
7
of Children and
Family Services Guardianship Administrator 
8
shall make good faith attempts to
notify the parent in writing 
9
and shall give written notice to the court and all
additional 
10
parties in writing that the adoption has not occurred or will 
11
not
occur and that the consent is void.  If the adoption by a 
12
specified person or
persons does not occur, no proceeding for 
13
termination of parental rights shall
be brought unless the 
14
biological parent who executed the consent to adoption by
a 
15
specified person or persons has been notified of the proceeding 
16
pursuant to
Section 7 of this Act or subsection (4) of Section 
17
2-13 of the Juvenile Court
Act of 1987.  The parent shall not 
18
need to take further action to revoke the
consent if the 
19
specified adoption does not occur, notwithstanding the

20
provisions of Section 11 of this Act.

21
    (6) The Department of Children and Family Services is 
22
authorized
to promulgate rules necessary to implement this 
23
subsection O.

24
    (7) The Department shall collect and maintain data 
25
concerning the efficacy
of specific consents.  This data shall 
26
include the number of specific consents
executed and their 
 


 






09600HB6080ham002
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LRB096 18717 AJO 38854 a




1
outcomes, including but not limited to the number of
children 
2
adopted pursuant to the consents, the number of children for 
3
whom
adoptions are not completed, and the reason or reasons why 
4
the adoptions are
not completed.

5
    P. If the person signing a consent is incarcerated or 
6
detained in a correctional facility, prison, jail, detention 
7
center, or other comparable institution, either in this State 
8
or any other jurisdiction, the execution of such consent may be 
9
acknowledged before social service personnel of such 
10
institution, or before a person designated by a court of 
11
competent jurisdiction.
12
    Q. A consent may be acknowledged telephonically, via 
13
audiovisual connection, or other electronic means, provided 
14
that a court of competent jurisdiction has entered an order 
15
approving the execution of the consent in such manner and has 
16
designated an individual to be physically present with the 
17
parent executing such consent in order to verify the identity 
18
of the parent.
19
    R. An agency whose representative is acknowledging a 
20
consent pursuant to this Section shall be a public child 
21
welfare agency, or a child welfare agency, or a child placing 
22
agency that is authorized or licensed in the State or 
23
jurisdiction in which the consent is signed. 
24
(Source: P.A. 96-601, eff. 8-21-09.)

 
25
    Section 99. Effective date. This Act takes effect January 
 


 






09600HB6080ham002
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LRB096 18717 AJO 38854 a




1
1, 2011.".