HB4028ham001 97TH GENERAL ASSEMBLY

Rep. Sara Feigenholtz

Filed: 3/20/2012

 

 


 

 


 
09700HB4028ham001LRB097 14710 AJO 67428 a

1
AMENDMENT TO HOUSE BILL 4028

2    AMENDMENT NO. ______. Amend House Bill 4028 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Adoption Act is amended by changing Section
510 as follows:
 
6    (750 ILCS 50/10)  (from Ch. 40, par. 1512)
7    Sec. 10. Forms of consent and surrender; execution and
8acknowledgment thereof.
9    A. The form of consent required for the adoption of a born
10child shall be substantially as follows:
11
FINAL AND IRREVOCABLE CONSENT TO ADOPTION
12    I, ...., (relationship, e.g., mother, father, relative,
13guardian) of ...., a ..male child, state:
14    That such child was born on .... at ....
15    That I reside at ...., County of .... and State of ....
16    That I am of the age of .... years.

 

 

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1    That I hereby enter my appearance in this proceeding and
2waive service of summons on me.
3    That I hereby acknowledge that I have been provided with a
4copy of the Birth Parent Rights and Responsibilities-Private
5Form before signing this Consent and that I have had time to
6read, or have had read to me, this Form. I understand that if I
7do not receive any of the rights as described in this Form, it
8shall not constitute a basis to revoke this Final and
9Irrevocable Consent.
10    That I do hereby consent and agree to the adoption of such
11child.
12    That I wish to and understand that by signing this consent
13I do irrevocably and permanently give up all custody and other
14parental rights I have to such child.
15    That I understand such child will be placed for adoption
16and that I cannot under any circumstances, after signing this
17document, change my mind and revoke or cancel this consent or
18obtain or recover custody or any other rights over such child.
19That I have read and understand the above and I am signing it
20as my free and voluntary act.
21    Dated (insert date).
22.........................
 
23    If under Section 8 the consent of more than one person is
24required, then each such person shall execute a separate
25consent.

 

 

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1    A-1. (1) The form of the Final and Irrevocable Consent to
2Adoption by a Specified Person or Persons: Non-DCFS Case set
3forth in this subsection A-1 is to be used by legal parents
4only. This form is not to be used in cases in which there is a
5pending petition under Section 2-13 of the Juvenile Court Act
6of 1987.
7    (2) The form of the Final and Irrevocable Consent to
8Adoption by a Specified Person or Persons in a non-DCFS case
9shall have the caption of the proceeding in which it is to be
10filed and shall be substantially as follows:
11
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
12
A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE
13    I, ...., (relationship, e.g., mother, father) of ...., a
14..male child, state:
15    1. That such child was born on ...., at ....., City of ...
16and State of ....
17    2. That I reside at ...., County of .... and State of ....
18    3. That I am of the age of .... years.
19    4. That I hereby enter my appearance in this proceeding and
20waive service of summons on me.
21    5. That I hereby acknowledge that I have been provided a
22copy of the Birth Parent Rights and Responsibilities-Private
23Form before signing this Consent and that I have had time to
24read, or have had read to me, this Form and that I understand
25the Rights and Responsibilities described in this Form. I
26understand that if I do not receive any of my rights as

 

 

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1described in said Form, it shall not constitute a basis to
2revoke this Final and Irrevocable Consent to Adoption by a
3Specified Person.
4    6. That I do hereby consent and agree to the adoption of
5such child by .... (specified persons) only.
6    7. That I wish to and understand that upon signing this
7consent I do irrevocably and permanently give up all custody
8and other parental rights I have to such child if such child is
9adopted by .... (specified person or persons). I hereby
10transfer all of my rights to the custody, care and control of
11such child to ............................. (specified person
12or persons).
13    8. That I understand such child will be adopted by
14....................... (specified person or persons) and that
15I cannot under any circumstances, after signing this document,
16change my mind and revoke or cancel this consent or obtain or
17recover custody or any other rights over such child if
18............................ (specified person or persons)
19adopt(s) such child; PROVIDED that each specified person has
20filed or shall file, within 60 days from the date hereof, a
21petition for the adoption of such child.
22    9. That if the specified person or persons designated
23herein do not file a petition for adoption within the
24time-frame specified above, or, if said petition for adoption
25is filed within the time-frame specified above but the adoption
26petition is dismissed with prejudice or the adoption proceeding

 

 

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1is otherwise concluded without an order declaring the child to
2be the adopted child of the specified person or persons, then I
3understand that I will receive written notice of such
4circumstances within 10 business days of their occurrence. I
5understand that the notice will be directed to me using the
6contact information I have provided in this consent. I
7understand that I will have 10 business days from the date that
8the written notice is sent to me to respond, within which time
9I may request the Court to declare this consent voidable and
10return the child to me. I further understand that the Court
11will make the final decision of whether or not the child will
12be returned to me. If I do not make such request within 10
13business days of the date of the notice, then I expressly waive
14any other notice or service of process in any legal proceeding
15for the adoption of the child.
16    10. That I expressly acknowledge that nothing in this
17Consent impairs the validity and absolute finality of this
18Consent under any circumstance other than those described in
19paragraph 9 of this Consent.
20    11. That I understand that I have a remaining duty and
21obligation to keep .............. (insert name and address of
22the attorney for the specified person or persons) informed of
23my current address or other preferred contact information until
24this adoption has been finalized. My failure to do so may
25result in the termination of my parental rights and the child
26being placed for adoption in another home.

 

 

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1    12. That I do expressly waive any other notice or service
2of process in any of the legal proceedings for the adoption of
3the child as long as the adoption proceeding by the specified
4person or persons is pending.
5    13. That I have read and understand the above and I am
6signing it as my free and voluntary act.
7    14. That I acknowledge that this consent is valid even if
8the specified person or persons separate or divorce or one of
9the specified persons dies prior to the entry of the final
10judgment for adoption.
11    Dated (insert date).
12    .............................................
13    Signature of parent.
14    .............................................
15    Address of parent.
16    .............................................
17    Phone number(s) of parent.
18    .............................................
19    Personal email(s) of parent.
20    .............................................
21    (3) The form of the certificate of acknowledgement for a
22Final and Irrevocable Consent for Adoption by a Specified
23Person or Persons: Non-DCFS Case shall be substantially as
24follows:
 
25STATE OF ..............)

 

 

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1                       ) SS.
2COUNTY OF .............)
3    I, .................... (Name of Judge or other person),
4..................... (official title, name, and address),
5certify that ............., personally known to me to be the
6same person whose name is subscribed to the foregoing Final and
7Irrevocable Consent for Adoption by a Specified Person or
8Persons; non-DCFS case, appeared before me this day in person
9and acknowledged that (she)(he) signed and delivered the
10consent as (her)(his) free and voluntary act, for the specified
11purpose. I am further satisfied that, before signing this
12Consent, ........ has read, or has had read to him or her, the
13Birth Parent Rights and Responsibilities-Private Form.
14    A-2. Birth Parent Rights and Responsibilities-Private
15Form. The Birth Parent Rights and Responsibilities-Private
16Form must be read by, or have been read to, any person
17executing a Final and Irrevocable Consent to Adoption under
18subsection A, a Final and Irrevocable Consent to Adoption by a
19Specified Person or Persons: Non-DCFS Case under subsection
20A-1, or a Consent to Adoption of Unborn Child under subsection
21B prior to the execution of said Consent. The form of the Birth
22Parent Rights and Responsibilities-Private Form shall be
23substantially as follows:
24
Birth Parent Rights and Responsibilities-Private Form
25    As a birth parent in the State of Illinois, you have the
26right:

 

 

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1    1. To have your own attorney represent you. The prospective
2adoptive parents may agree to pay for the cost of your attorney
3in a manner consistent with Illinois law, but they are not
4required to do so.
5    2. To be treated with dignity and respect at all times and
6to make decisions free from coercion and pressure.
7    3. To receive counseling before and after signing a Final
8and Irrevocable Consent to Adoption ("Consent"), a Final and
9Irrevocable Consent to Adoption by a Specified Person or
10Persons: Non-DCFS Case ("Specified Consent"), or a Consent to
11Adoption of Unborn Child ("Unborn Consent"). The prospective
12adoptive parents may agree to pay for the cost of counseling in
13a manner consistent with Illinois law, but they are not
14required to do so.
15    4. To ask to be involved in choosing your child's
16prospective adoptive parents and to ask to meet them.
17    5. To ask your child's prospective adoptive parents any
18questions that pertain to your decision to place your child
19with them.
20    6. To see your child before signing a Consent or Specified
21Consent.
22    7. To request contact with your child and/or the child's
23prospective adoptive parents, with the understanding that any
24promises regarding contact with your child or receipt of
25information about the child after signing a Consent, Specified
26Consent, or Unborn Consent cannot be enforced under Illinois

 

 

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

 

 

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1    2. To voluntarily provide all known medical, background,
2and family information about yourself and your immediate family
3to your child's prospective adoptive parents or their attorney.
4For the health of your child, you are strongly encouraged, but
5not required, to provide all known medical, background, and
6family history information about yourself and your family to
7your child's prospective adoptive parents or their attorney.
8    3. (Birth mothers only) To accurately complete an Affidavit
9of Identification, which identifies the father of the child
10when known, with the understanding that a birth mother has a
11right to decline to identify the birth father.
12    4. To not accept financial support or reimbursement of
13pregnancy related expenses simultaneously from more than one
14source.
15    B. The form of consent required for the adoption of an
16unborn child shall be substantially as follows:
17
CONSENT TO ADOPTION OF UNBORN CHILD
18    I, ...., state:
19    That I am the father of a child expected to be born on or
20about .... to .... (name of mother).
21    That I reside at .... County of ...., and State of .....
22    That I am of the age of .... years.
23    That I hereby enter my appearance in such adoption
24proceeding and waive service of summons on me.
25    That I hereby acknowledge that I have been provided with a
26copy of the Birth Parent Rights and Responsibilities-Private

 

 

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1Form before signing this Consent, and that I have had time to
2read, or have had read to me, this Form. I understand that if I
3do not receive any of the rights as described in this Form, it
4shall not constitute a basis to revoke this Consent to Adoption
5of Unborn Child.
6    That I do hereby consent and agree to the adoption of such
7child, and that I have not previously executed a consent or
8surrender with respect to such child.
9    That I wish to and do understand that by signing this
10consent I do irrevocably and permanently give up all custody
11and other parental rights I have to such child, except that I
12have the right to revoke this consent by giving written notice
13of my revocation not later than 72 hours after the birth of the
14child.
15    That I understand such child will be placed for adoption
16and that, except as hereinabove provided, I cannot under any
17circumstances, after signing this document, change my mind and
18revoke or cancel this consent or obtain or recover custody or
19any other rights over such child.
20    That I have read and understand the above and I am signing
21it as my free and voluntary act.
22    Dated (insert date).
23........................
24    B-5. (1) The parent of a child may execute a consent to
25standby adoption by a specified person or persons. A consent
26under this subsection B-5 shall be acknowledged by a parent

 

 

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1pursuant to subsection H and subsection K of this Section. The
2form of consent required for the standby adoption of a born
3child effective at a future date when the consenting parent of
4the child dies or requests that a final judgment of adoption be
5entered shall be substantially as follows:
6
FINAL AND IRREVOCABLE CONSENT
7
TO STANDBY ADOPTION
8    I, ..., (relationship, e.g. mother or father) of ...., a
9..male child, state:
10    That the child was born on .... at .....
11    That I reside at ...., County of ...., and State of .....
12    That I am of the age of .... years.
13    That I hereby enter my appearance in this proceeding and
14waive service of summons on me in this action only.
15    That I do hereby consent and agree to the standby adoption
16of the child, and that I have not previously executed a consent
17or surrender with respect to the child.
18    That I wish to and understand that by signing this consent
19I do irrevocably and permanently give up all custody and other
20parental rights I have to the child, effective upon (my death)
21(the child's other parent's death) or upon (my) (the other
22parent's) request for the entry of a final judgment for
23adoption if ..... (specified person or persons) adopt my child.
24    That I understand that until (I die) (the child's other
25parent dies), I retain all legal rights and obligations
26concerning the child, but at that time, I irrevocably give all

 

 

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1custody and other parental rights to .... (specified person or
2persons).
3    I understand my child will be adopted by ....... (specified
4person or persons) only and that I cannot, under any
5circumstances, after signing this document, change my mind and
6revoke or cancel this consent or obtain or recover custody or
7any other rights over my child if ..... (specified person or
8persons) adopt my child.
9    I understand that this consent to standby adoption is valid
10only if the petition for standby adoption is filed and that if
11....... (specified person or persons), for any reason, cannot
12or will not file a petition for standby adoption or if his,
13her, or their petition for standby adoption is denied, then
14this consent is void. I have the right to notice of any other
15proceeding that could affect my parental rights.
16    That I have read and understand the above and I am signing
17it as my free and voluntary act.
18    Dated (insert date).
19....................
 
20    If under Section 8 the consent of more than one person is
21required, then each such person shall execute a separate
22consent. A separate consent shall be executed for each child.
23    (2) If the parent consents to a standby adoption by 2
24specified persons, then the form shall contain 2 additional
25paragraphs in substantially the following form:

 

 

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1    If .... (specified persons) obtain a judgment of
2dissolution of marriage before the judgment for adoption is
3entered, then ..... (specified person) shall adopt my child. I
4understand that I cannot change my mind and revoke this consent
5or obtain or recover custody of my child if ..... (specified
6persons) obtain a judgment of dissolution of marriage and .....
7(specified person) adopts my child. I understand that I cannot
8change my mind and revoke this consent if ...... (specified
9persons) obtain a judgment of dissolution of marriage before
10the adoption is final. I understand that this consent to
11adoption has no effect on who will get custody of my child if
12..... (specified persons) obtain a judgment of dissolution of
13marriage after the adoption is final. I understand that if
14either ..... (specified persons) dies before the petition to
15adopt my child is granted, then the surviving person may adopt
16my child. I understand that I cannot change my mind and revoke
17this consent or obtain or recover custody of my child if the
18surviving person adopts my child.
19    A consent to standby adoption by specified persons on this
20form shall have no effect on a court's determination of custody
21or visitation under the Illinois Marriage and Dissolution of
22Marriage Act if the marriage of the specified persons is
23dissolved before the adoption is final.
24    (3) The form of the certificate of acknowledgement for a
25Final and Irrevocable Consent for Standby Adoption shall be
26substantially as follows:
 

 

 

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1STATE OF .....)
2              ) SS.
3COUNTY OF ....)
 
4    I, ....... (name of Judge or other person) ..... (official
5title, name, and address), certify that ......., personally
6known to me to be the same person whose name is subscribed to
7the foregoing Final and Irrevocable Consent to Standby
8Adoption, appeared before me this day in person and
9acknowledged that (she) (he) signed and delivered the consent
10as (her) (his) free and voluntary act, for the specified
11purpose.
12    I have fully explained that this consent to adoption is
13valid only if the petition to adopt is filed, and that if the
14specified person or persons, for any reason, cannot or will not
15adopt the child or if the adoption petition is denied, then
16this consent will be void. I have fully explained that if the
17specified person or persons adopt the child, by signing this
18consent (she) (he) is irrevocably and permanently
19relinquishing all parental rights to the child, and (she) (he)
20has stated that such is (her) (his) intention and desire.
21    Dated (insert date).
22    Signature ..............................
23    (4) If a consent to standby adoption is executed in this
24form, the consent shall be valid only if the specified person

 

 

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1or persons adopt the child. The consent shall be void if:
2    (a) the specified person or persons do not file a petition
3for standby adoption of the child; or
4    (b) a court denies the standby adoption petition.
5    The parent shall not need to take further action to revoke
6the consent if the standby adoption by the specified person or
7persons does not occur, notwithstanding the provisions of
8Section 11 of this Act.
9    C. The form of surrender to any agency given by a parent of
10a born child who is to be subsequently placed for adoption
11shall be substantially as follows and shall contain such other
12facts and statements as the particular agency shall require.
13
FINAL AND IRREVOCABLE SURRENDER
14
FOR PURPOSES OF ADOPTION
15    I, .... (relationship, e.g., mother, father, relative,
16guardian) of ...., a ..male child, state:
17    That such child was born on ...., at .....
18    That I reside at ...., County of ...., and State of .....
19    That I am of the age of .... years.
20    That I do hereby surrender and entrust the entire custody
21and control of such child to the .... (the "Agency"), a
22(public) (licensed) child welfare agency with its principal
23office in the City of ...., County of .... and State of ....,
24for the purpose of enabling it to care for and supervise the
25care of such child, to place such child for adoption and to
26consent to the legal adoption of such child.

 

 

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1    That I hereby grant to the Agency full power and authority
2to place such child with any person or persons it may in its
3sole discretion select to become the adopting parent or parents
4and to consent to the legal adoption of such child by such
5person or persons; and to take any and all measures which, in
6the judgment of the Agency, may be for the best interests of
7such child, including authorizing medical, surgical and dental
8care and treatment including inoculation and anaesthesia for
9such child.
10    That I wish to and understand that by signing this
11surrender I do irrevocably and permanently give up all custody
12and other parental rights I have to such child.
13    That I understand I cannot under any circumstances, after
14signing this surrender, change my mind and revoke or cancel
15this surrender or obtain or recover custody or any other rights
16over such child.
17    That I have read and understand the above and I am signing
18it as my free and voluntary act.
19    Dated (insert date).
20........................
21    C-5. The form of a Final and Irrevocable Designated
22Surrender for Purposes of Adoption to any agency given by a
23parent of a born child who is to be subsequently placed for
24adoption is to be used by legal parents only. The form shall be
25substantially as follows and shall contain such other facts and
26statements as the particular agency shall require:

 

 

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1
FINAL AND IRREVOCABLE DESIGNATED SURRENDER
2
FOR PURPOSES OF ADOPTION
3    I, .... (relationship, e.g., mother, father, relative,
4guardian) of ...., a ..male child, state:
5    1. That such child was born on ...., at .....
6    2. That I reside at ...., County of ...., and State of
7.....
8    3. That I am of the age of .... years.
9    4. That I do hereby surrender and entrust the entire
10custody and control of such child to the .... (the "Agency"), a
11(public) (licensed) child welfare agency with its principal
12office in the City of ...., County of .... and State of ....,
13for the purpose of enabling it to care for and supervise the
14care of such child, to place such child for adoption with
15............................. (specified person or persons)
16and to consent to the legal adoption of such child and to take
17any and all measures which, in the judgment of the Agency, may
18be for the best interests of such child, including authorizing
19medical, surgical and dental care and treatment including
20inoculation and anesthesia for such child.
21    5. That I wish to and understand that by signing this
22surrender I do irrevocably and permanently give up all custody
23and other parental rights I have to such child.
24    6. That if the petition for adoption is not filed by the
25specified person or persons designated herein or, if the
26petition for adoption is filed but the adoption petition is

 

 

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1dismissed with prejudice or the adoption proceeding is
2otherwise concluded without an order declaring the child to be
3the adopted child of each specified person, then I understand
4that the Agency will provide notice to me within 10 business
5days and that such notice will be directed to me using the
6contact information I have provided to the Agency. I understand
7that I will have 10 business days from the date that the Agency
8sends me its notice to respond, within which time I may choose
9to designate other adoptive parent(s). However, I acknowledge
10that the Agency has full power and authority to place the child
11for adoption with any person or persons it may in its sole
12discretion select to become the adopting parent or parents and
13to consent to the legal adoption of the child by such person or
14persons.
15    7. That I acknowledge that this surrender is valid even if
16the specified persons separate or divorce or one of the
17specified persons dies prior to the entry of the final judgment
18for adoption.
19    8. That I expressly acknowledge that the above paragraphs 6
20and 7 do not impair the validity and absolute finality of this
21surrender under any circumstance.
22    9. That I understand that I have a remaining obligation to
23keep the Agency informed of my current contact information
24until the adoption of the child has been finalized if I wish to
25be notified in the event the adoption by the specified
26person(s) cannot proceed.

 

 

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1    10. That I understand I cannot under any circumstances,
2after signing this surrender, change my mind and revoke or
3cancel this surrender or obtain or recover custody or any other
4rights over such child.
5    11. That I have read and understand the above and I am
6signing it as my free and voluntary act.
7    Dated (insert date).
8..............................
9    D. The form of surrender to an agency given by a parent of
10an unborn child who is to be subsequently placed for adoption
11shall be substantially as follows and shall contain such other
12facts and statements as the particular agency shall require.
13
SURRENDER OF UNBORN CHILD FOR
14
PURPOSES OF ADOPTION
15    I, .... (father), state:
16    That I am the father of a child expected to be born on or
17about .... to .... (name of mother).
18    That I reside at ...., County of ...., and State of .....
19    That I am of the age of .... years.
20    That I do hereby surrender and entrust the entire custody
21and control of such child to the .... (the "Agency"), a
22(public) (licensed) child welfare agency with its principal
23office in the City of ...., County of .... and State of ....,
24for the purpose of enabling it to care for and supervise the
25care of such child, to place such child for adoption and to
26consent to the legal adoption of such child, and that I have

 

 

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1not previously executed a consent or surrender with respect to
2such child.
3    That I hereby grant to the Agency full power and authority
4to place such child with any person or persons it may in its
5sole discretion select to become the adopting parent or parents
6and to consent to the legal adoption of such child by such
7person or persons; and to take any and all measures which, in
8the judgment of the Agency, may be for the best interests of
9such child, including authorizing medical, surgical and dental
10care and treatment, including inoculation and anaesthesia for
11such child.
12    That I wish to and understand that by signing this
13surrender I do irrevocably and permanently give up all custody
14and other parental rights I have to such child.
15    That I understand I cannot under any circumstances, after
16signing this surrender, change my mind and revoke or cancel
17this surrender or obtain or recover custody or any other rights
18over such child, except that I have the right to revoke this
19surrender by giving written notice of my revocation not later
20than 72 hours after the birth of such child.
21    That I have read and understand the above and I am signing
22it as my free and voluntary act.
23    Dated (insert date).
24........................
25    E. The form of consent required from the parents for the
26adoption of an adult, when such adult elects to obtain such

 

 

09700HB4028ham001- 22 -LRB097 14710 AJO 67428 a

1consent, shall be substantially as follows:
2
CONSENT
3    I, ...., (father) (mother) of ...., an adult, state:
4    That I reside at ...., County of .... and State of .....
5    That I do hereby consent and agree to the adoption of such
6adult by .... and .....
7    Dated (insert date).
8.........................
9    F. The form of consent required for the adoption of a child
10of the age of 14 years or upwards, or of an adult, to be given
11by such person, shall be substantially as follows:
12
CONSENT
13    I, ...., state:
14    That I reside at ...., County of .... and State of .....
15That I am of the age of .... years. That I consent and agree to
16my adoption by .... and .....
17    Dated (insert date).
18........................
19    G. The form of consent given by an agency to the adoption
20by specified persons of a child previously surrendered to it
21shall set forth that the agency has the authority to execute
22such consent. The form of consent given by a guardian of the
23person of a child sought to be adopted, appointed by a court of
24competent jurisdiction, shall set forth the facts of such
25appointment and the authority of the guardian to execute such
26consent.

 

 

09700HB4028ham001- 23 -LRB097 14710 AJO 67428 a

1    H. A consent (other than that given by an agency, or
2guardian of the person of the child sought to be adopted who
3was appointed by a court of competent jurisdiction) shall be
4acknowledged by a parent before a judge of a court of competent
5jurisdiction or, except as otherwise provided in this Act,
6before a representative of an agency, or before a person, other
7than the attorney for the prospective adoptive parent or
8parents, designated by a court of competent jurisdiction.
9    I. A surrender, or any other document equivalent to a
10surrender, by which a child is surrendered to an agency shall
11be acknowledged by the person signing such surrender, or other
12document, before a judge of a court of competent jurisdiction,
13or, except as otherwise provided in this Act, before a
14representative of an agency, or before a person designated by a
15court of competent jurisdiction.
16    J. The form of the certificate of acknowledgment for a
17consent, a surrender, or any other document equivalent to a
18surrender, shall be substantially as follows:
19STATE OF ....)
20             ) SS.
21COUNTY OF ...)
22    I, .... (Name of judge or other person), .... (official
23title, name and location of court or status or position of
24other person), certify that ...., personally known to me to be
25the same person whose name is subscribed to the foregoing
26(consent) (surrender), appeared before me this day in person

 

 

09700HB4028ham001- 24 -LRB097 14710 AJO 67428 a

1and acknowledged that (she) (he) signed and delivered such
2(consent) (surrender) as (her) (his) free and voluntary act,
3for the specified purpose.
4    I have fully explained that by signing such (consent)
5(surrender) (she) (he) is irrevocably relinquishing all
6parental rights to such child or adult and (she) (he) has
7stated that such is (her) (his) intention and desire. (Add if
8Consent only) I am further satisfied that, before signing this
9Consent, ........ has read, or has had read to him or her, the
10Birth Parent Rights and Responsibilities-Private Form.
11    Dated (insert date).
12    Signature ...............
13    K. When the execution of a consent or a surrender is
14acknowledged before someone other than a judge, such other
15person shall have his or her signature on the certificate
16acknowledged before a notary public, in form substantially as
17follows:
18STATE OF ....)
19             ) SS.
20COUNTY OF ...)
21    I, a Notary Public, in and for the County of ......, in the
22State of ......, certify that ...., personally known to me to
23be the same person whose name is subscribed to the foregoing
24certificate of acknowledgment, appeared before me in person and
25acknowledged that (she) (he) signed such certificate as (her)
26(his) free and voluntary act and that the statements made in

 

 

09700HB4028ham001- 25 -LRB097 14710 AJO 67428 a

1the certificate are true.
2    Dated (insert date).
3    
Signature ...................... Notary Public
4
(official seal)

 
5    There shall be attached a certificate of magistracy, or
6other comparable proof of office of the notary public
7satisfactory to the court, to a consent signed and acknowledged
8in another state.
9    L. A surrender or consent executed and acknowledged outside
10of this State, either in accordance with the law of this State
11or in accordance with the law of the place where executed, is
12valid.
13    M. Where a consent or a surrender is signed in a foreign
14country, the execution of such consent shall be acknowledged or
15affirmed in a manner conformable to the law and procedure of
16such country.
17    N. If the person signing a consent or surrender is in the
18military service of the United States, the execution of such
19consent or surrender may be acknowledged before a commissioned
20officer and the signature of such officer on such certificate
21shall be verified or acknowledged before a notary public or by
22such other procedure as is then in effect for such division or
23branch of the armed forces.
24    O. (1) The parent or parents of a child in whose interests
25a petition under Section 2-13 of the Juvenile Court Act of 1987

 

 

09700HB4028ham001- 26 -LRB097 14710 AJO 67428 a

1is pending may, with the approval of the designated
2representative of the Department of Children and Family
3Services ("Department" or "DCFS"), execute a consent to
4adoption by a specified person or persons:
5        (a) in whose physical custody the child has resided for
6    at least 6 months; or
7        (b) in whose physical custody at least one sibling of
8    the child who is the subject of this consent has resided
9    for at least 6 months, and the child who is the subject of
10    this consent is currently residing in this foster home; or
11        (c) in whose physical custody a child under one year of
12    age has resided for at least 3 months.
13The court may waive the time frames in subdivisions (a), (b),
14and (c) for good cause shown if the court finds it to be in the
15child's best interests.
16A consent under this subsection O shall be acknowledged by a
17parent pursuant to subsection H and subsection K of this
18Section.
19    (2) The final and irrevocable consent to adoption by a
20specified person or persons in a Department of Children and
21Family Services (DCFS) case consent to adoption by a specified
22person or persons shall have the caption of the proceeding in
23which it is to be filed and shall be substantially as follows:
24
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
25
A SPECIFIED PERSON OR PERSONS: DCFS CASE
26    I, ......................................, the

 

 

09700HB4028ham001- 27 -LRB097 14710 AJO 67428 a

1.................. (mother or father) of a ....male child,
2state:
3        1. My child ............................ (name of
4    child) was born on (insert date) at ....................
5    Hospital in the municipality of ........., in
6    ................ County, State of ...............
7        2. I reside at ......................, County of
8    ............. and State of ..............
9        Mail may also be sent to me at this address
10    ............................, in care of .................
11        My home telephone number is..........................
12        My cell telephone number is..........................
13        My e-mail address is.................................
14        3. I, ..........................., am .... years old.
15        4. I enter my appearance in this action for my child to
16    be adopted to adopt my child by the person or persons
17    specified herein by me and waive service of summons on me
18    in this action only.
19        5. I hereby acknowledge that I have been provided a
20    copy of the Birth Parent Rights and Responsibilities for
21    DCFS Cases before signing this Consent and that I have had
22    time to read this form or have it read to me and that I
23    understand the rights and responsibilities described in
24    this form. I understand that if I do not receive any of my
25    rights as described in the form, it shall not constitute a
26    basis to revoke this Final and Irrevocable Consent to

 

 

09700HB4028ham001- 28 -LRB097 14710 AJO 67428 a

1    Adoption by a Specified Person or Persons.
2        6. I do hereby consent and agree to the adoption of
3    such child by .......... (specified person or persons)
4    only.
5        7. I wish to sign this consent and I understand that by
6    signing this consent I irrevocably and permanently give up
7    all my parental rights I have to my child.
8        8. I understand that this consent allows my child to be
9    adopted by .......... only and that I cannot under any
10    circumstances after signing this document change my mind
11    and revoke or cancel this consent.
12        9. I understand that this consent will be void if:
13            (a) the Department places my child with someone
14        other than the specified person or persons; or
15            (b) a court denies the adoption petition for the
16        specified person or persons to adopt my child; or
17            (c) the DCFS Guardianship Administrator refuses to
18        consent to my child's adoption by the specified person
19        or persons on the basis that the adoption is not in my
20        child's best interests.
21        I understand that if this consent is void I have
22    parental rights to my child, subject to any applicable
23    court orders including those entered under Article II of
24    the Juvenile Court Act of 1987, unless and until I sign a
25    new consent or surrender or my parental rights are
26    involuntarily terminated. I understand that if this

 

 

09700HB4028ham001- 29 -LRB097 14710 AJO 67428 a

1    consent is void, my child may be adopted by someone other
2    than the specified person or persons only if I sign a new
3    consent or surrender, or my parental rights are
4    involuntarily terminated. I understand that if this
5    consent is void, the Department will notify me within 30
6    days using the addresses and telephone numbers I provided
7    in paragraph 2 of this form. I understand that if I receive
8    such a notice, it is very important that I contact the
9    Department immediately, and preferably within 30 days, to
10    have input into the plan for my child's future.
11        10. I understand that if a petition for adoption of my
12    child is filed by someone other than the specified person
13    or persons, the Department will notify me within 14 days
14    after the Department becomes aware of the petition. The
15    fact that someone other than the specified person or
16    persons files a petition to adopt my child does not make
17    this consent void.
18        11. If a person other than the specified person or
19    persons files a petition to adopt my child or if the
20    consent is void under paragraph 9, the Department will send
21    written notice to me using the mailing address and email
22    address provided by me in paragraph 2 of this form. The
23    Department will also contact me using the telephone numbers
24    I provided in paragraph 2 of this form. It is very
25    important that I let the Department know if any of my
26    contact information changes. If I do not let the Department

 

 

09700HB4028ham001- 30 -LRB097 14710 AJO 67428 a

1    know if any of my contact information changes, I understand
2    that I may not receive notification from the Department if
3    this consent is void or if someone other than the specified
4    person or persons files a petition to adopt my child. If
5    any of my contact information changes, I should immediately
6    notify:
7        Caseworker's name and telephone number:
8    ............................................................;
9        Agency name, address, zip code, and telephone number:
10    ............................................................;
11        Supervisor's name and telephone number:
12    ............................................................;
13    DCFS Advocacy Office for Children and Families:
14    800-232-3798.
15        12. I expressly acknowledge that paragraph 9 (and
16    paragraphs 8a and 8b, if applicable) do not impair the
17    validity and finality of this consent under any
18    circumstances.
19         I consent to the adoption of my child by
20    ............................. (specified person or
21    persons) only.
22         I wish to sign this consent and I understand that by
23    signing this consent I irrevocably and permanently give up
24    all parental rights I have to my child if my child is
25    adopted by ............................. (specified person
26    or persons).

 

 

09700HB4028ham001- 31 -LRB097 14710 AJO 67428 a

1         I understand my child will be adopted by
2    ............................. (specified person or
3    persons) only and that I cannot under any circumstances,
4    after signing this document, change my mind and revoke or
5    cancel this consent or obtain or recover custody or any
6    other rights over my child if ............................
7    (specified person or persons) adopt my child.
8         I understand that this consent to adoption is valid
9    only if the petition to adopt is filed within one year from
10    the date that I sign it and that if .......................
11    (specified person or persons), for any reason, cannot or
12    will not file a petition to adopt my child within that one
13    year period or if their adoption petition is denied, then
14    this consent will be voidable after one year upon the
15    timely filing of my motion. If I file this motion before
16    the filing of the petition for adoption, I understand that
17    the court shall revoke this specific consent. I have the
18    right to notice of any other proceeding that could affect
19    my parental rights, except for the proceeding for
20    ............. (specified person or persons) to adopt my
21    child.
22         13. 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        Signature of parent

 

 

09700HB4028ham001- 32 -LRB097 14710 AJO 67428 a

1    (3) If the parent consents to an adoption by 2 specified
2persons, then the form shall contain 2 additional paragraphs in
3substantially the following form:
4        8a. If ............... (specified persons) get a
5    divorce or are granted a dissolution of a civil union
6    before the petition to adopt my child is granted, this
7    consent is valid for ........... (specified person) to
8    adopt my child. I understand that I cannot change my mind
9    or revoke this consent or recover custody of my child on
10    the basis that the specified persons divorce or are granted
11    a dissolution of a civil union. then .......... (specified
12    person) shall adopt my child. I understand that I cannot
13    change my mind and revoke this consent or obtain or recover
14    custody over my child if ............. (specified persons)
15    divorce and ............. (specified person) adopts my
16    child. I understand that I cannot change my mind and revoke
17    this 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        8b. I understand that if either ...............
23    (specified persons) dies before the petition to adopt my
24    child is granted, this consent remains valid for the
25    surviving person to adopt my child. I understand that I
26    cannot change my mind or revoke this consent or recover

 

 

09700HB4028ham001- 33 -LRB097 14710 AJO 67428 a

1    custody of my child on the basis that one of the specified
2    persons dies. then the surviving person can adopt my child.
3    I understand that I cannot change my mind and revoke this
4    consent or obtain or recover custody over my child if the
5    surviving person adopts my child.
6    A consent to adoption by specified persons on this form
7shall have no effect on a court's determination of custody or
8visitation under the Illinois Marriage and Dissolution of
9Marriage Act if the marriage of the specified persons is
10dissolved after the adoption is final.
11    (4) The form of the certificate of acknowledgement for a
12Final and Irrevocable Consent for Adoption by a Specified
13Person or Persons: DCFS Case shall be substantially as follows:
 
14STATE OF ..............)
15                       ) SS.
16COUNTY OF .............)
 
17    I, .................... (Name of Judge or other person),
18..................... (official title, name, and address),
19certify that ............., personally known to me to be the
20same person whose name is subscribed to the foregoing Final and
21Irrevocable Consent for Adoption by a Specified Person or
22Persons: DCFS Case, appeared before me this day in person and
23acknowledged that (she)(he) signed and delivered the consent as
24(her)(his) free and voluntary act, for the specified purpose.

 

 

09700HB4028ham001- 34 -LRB097 14710 AJO 67428 a

1    I have fully explained that this consent to adoption is
2valid only if the petition to adopt is filed within one year
3from the date that it is signed, and that if the specified
4person or persons, for any reason, cannot or will not adopt the
5child or if the adoption petition is denied, then this consent
6will be voidable after one year upon the timely filing of a
7motion by the parent to revoke the consent. I explained that if
8this motion is filed before the filing of the petition for
9adoption, the court shall revoke this specific consent. I have
10fully explained that if the specified person or persons adopt
11the child, by signing this consent this parent is irrevocably
12and permanently relinquishing all parental rights to the child
13so that the child may be adopted by a specified person or
14persons, and this parent has stated that such is (her)(his)
15intention and desire. I have fully explained that this consent
16is void only if:
17        (a) the placement is disrupted and the child is moved
18    to a different placement; or
19        (b) a court denies the petition for adoption; or
20        (c) the Department of Children and Family Services
21    Guardianship Administrator refuses to consent to the
22    child's adoption by a specified person or persons on the
23    basis that the adoption is not in the child's best
24    interests.
25    Dated (insert date).
26    ...............................

 

 

09700HB4028ham001- 35 -LRB097 14710 AJO 67428 a

1    Signature
2    (5) If a consent to adoption by a specified person or
3persons is executed in this form, the following provisions
4shall apply. The consent shall be valid only for the if that
5specified person or persons to adopt the child. The consent
6shall be void voidable after one year if:
7        (a) the placement disrupts and the child is moved to
8    another placement the specified person or persons do not
9    file a petition to adopt the child within one year after
10    the consent is signed and the parent files a timely motion
11    to revoke this consent. If this motion is filed before the
12    filing of the petition for adoption the court shall revoke
13    this consent; or
14        (b) a court denies the petition for adoption a court
15    denies the adoption petition; or
16        (c) the Department of Children and Family Services
17    Guardianship Administrator refuses to consent to the
18    child's adoption by the specified person or persons on the
19    basis that the adoption is not in the child's best
20    interests determines that the specified person or persons
21    will not or cannot complete the adoption, or in the best
22    interests of the child should not adopt the child.
23    If the consent is void under this Section, the parent shall
24not need to take further action to revoke the consent. No
25proceeding for termination of parental rights shall be brought
26unless the parent who executed the consent to adoption by a

 

 

09700HB4028ham001- 36 -LRB097 14710 AJO 67428 a

1specified person or persons has been notified of the
2proceedings pursuant to Section 7 of this Act or subsection (4)
3of Section 2-13 of the Juvenile Court Act of 1987. Within 30
4days of the consent becoming void, the Department of Children
5and Family Services Guardianship Administrator shall make good
6faith attempts to notify the parent in writing and shall give
7written notice to the court and all additional parties in
8writing that the adoption has not occurred or will not occur
9and that the consent is void. If the adoption by a specified
10person or persons does not occur, no proceeding for termination
11of parental rights shall be brought unless the biological
12parent who executed the consent to adoption by a specified
13person or persons has been notified of the proceeding pursuant
14to Section 7 of this Act or subsection (4) of Section 2-13 of
15the Juvenile Court Act of 1987. The parent shall not need to
16take further action to revoke the consent if the specified
17adoption does not occur, notwithstanding the provisions of
18Section 11 of this Act.
19    (6) The Department of Children and Family Services is
20authorized to promulgate rules necessary to implement this
21subsection O.
22    (7) (Blank). The Department shall collect and maintain data
23concerning the efficacy of specific consents. This data shall
24include the number of specific consents executed and their
25outcomes, including but not limited to the number of children
26adopted pursuant to the consents, the number of children for

 

 

09700HB4028ham001- 37 -LRB097 14710 AJO 67428 a

1whom adoptions are not completed, and the reason or reasons why
2the adoptions are not completed.
3    (8) The Department of Children and Family Services shall
4promulgate a rule and procedures regarding Consents to Adoption
5by a Specified Person or Persons in DCFS cases. The rule and
6procedures shall provide for the development of the Birth
7Parent Rights and Responsibilities Form for DCFS Cases.
8    (9) A consent to adoption by specified persons on this
9consent form shall have no effect on a court's determination of
10custody or visitation under the Illinois Marriage and
11Dissolution of Marriage Act or the Illinois Religious Freedom
12Protection and Civil Union Act if the marriage or civil union
13of the specified persons is dissolved after the adoption is
14final.
15    P. If the person signing a consent is incarcerated or
16detained in a correctional facility, prison, jail, detention
17center, or other comparable institution, either in this State
18or any other jurisdiction, the execution of such consent may be
19acknowledged before social service personnel of such
20institution, or before a person designated by a court of
21competent jurisdiction.
22    Q. A consent may be acknowledged telephonically, via
23audiovisual connection, or other electronic means, provided
24that a court of competent jurisdiction has entered an order
25approving the execution of the consent in such manner and has
26designated an individual to be physically present with the

 

 

09700HB4028ham001- 38 -LRB097 14710 AJO 67428 a

1parent executing such consent in order to verify the identity
2of the parent.
3    R. An agency whose representative is acknowledging a
4consent pursuant to this Section shall be a public child
5welfare agency, or a child welfare agency, or a child placing
6agency that is authorized or licensed in the State or
7jurisdiction in which the consent is signed.
8    S. The form of waiver by a putative or legal father of a
9born or unborn child shall be substantially as follows:
 
10
FINAL AND IRREVOCABLE
11
WAIVER OF PARENTAL RIGHTS OF PUTATIVE OR LEGAL FATHER

 
12    I, .................... , state under oath or affirm as
13follows:
14        1. That the biological mother ............... has
15    named me as a possible biological or legal father of her
16    minor child who was born, or is expected to be born on
17    ..........., ......, in the City/Town of........., State
18    of ...........
19        2. That I understand that the biological mother
20    ............. intends to or has placed the child for
21    adoption.
22        3. That I reside at ................, in the City/Town
23    of..........., State of ................
24        4. That I am ................ years of age and my date

 

 

09700HB4028ham001- 39 -LRB097 14710 AJO 67428 a

1    of birth is ..............., .............
2        5. That I (select one):
3            ..... am married to the biological mother.
4            ..... am not married to the biological mother and
5        have not been married to the biological mother within
6        300 days before the child's birth or expected date of
7        child's birth.
8            ..... am not currently married to the biological
9        mother, but was married to the biological mother,
10        within 300 days before the child's birth or expected
11        date of child's birth.
12        6. That I (select one):
13            ..... neither admit nor deny that I am the
14        biological father of the child.
15            ..... deny that I am the biological father of the
16        child.
17        7. That I hereby agree to the termination of my
18    parental rights, if any, without further notice to me of
19    any proceeding for the adoption of the minor child, even if
20    I have taken any action to establish parental rights or
21    take any such action in the future including registering
22    with any putative father registry.
23        8. That I understand that by signing this Waiver I do
24    irrevocably and permanently give up all custody and other
25    parental rights I may have to such child.
26        9. That I understand that this Waiver is FINAL AND

 

 

09700HB4028ham001- 40 -LRB097 14710 AJO 67428 a

1    IRREVOCABLE and that I am permanently barred from
2    contesting any proceeding for the adoption of the child
3    after I sign this Waiver.
4        10. That I waive any further service of summons or
5    other pleadings in any proceeding to terminate parental
6    rights, if any to this child, or any proceeding for
7    adoption of this child.
8        11. That I understand that if a final judgment or order
9    of adoption for this child is not entered, then any
10    parental rights or responsibilities that I may have remain
11    intact.
12        12. That I have read and understand the above and that
13    I am signing it as my free and voluntary act.
 
14    Dated: ................... , ..............
15    ...........................................
16    Signature
 
17
OATH
18I have been duly sworn and I state under oath that I have read
19and understood this Final and Irrevocable Waiver of Parental
20Rights of Putative or Legal Father. The facts contained in it
21are true and correct to the best of my knowledge. I have signed
22this document as my free and voluntary act in order to
23facilitate the adoption of the child.
 

 

 

09700HB4028ham001- 41 -LRB097 14710 AJO 67428 a

1..............................
2Signature
 
3Signed and Sworn before me on
4this ............ day
5of ..........., 20....
 
6...................
7Notary Public
8(Source: P.A. 96-601, eff. 8-21-09; 96-1461, eff. 1-1-11;
997-493, eff. 8-22-11.)
 
10    Section 99. Effective date. This Act takes effect January
111, 2013.".