Full Text of HB5155 100th General Assembly
HB5155enr 100TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning civil law.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 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. | 9 | | A. The form of consent required for the
adoption of a born | 10 | | child shall be substantially as follows:
| 11 | | FINAL AND IRREVOCABLE CONSENT TO ADOPTION
| 12 | | I, ...., (relationship, e.g., mother, father, relative, | 13 | | guardian)
of ...., a .. male or female (circle one) child, | 14 | | state:
| 15 | | That such child was born on .... at ....
| 16 | | That I reside at ...., County of .... and State of ....
| 17 | | That I am of the age of .... years.
| 18 | | That I hereby enter my appearance in this proceeding and | 19 | | waive
service of summons on me.
| 20 | | That I hereby acknowledge that I have been provided with a | 21 | | copy of the Birth Parent Rights and Responsibilities-Private |
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| 1 | | Form before signing this Consent and that I have had time to | 2 | | read, or have had read to me, this Form. I understand that if I | 3 | | do not receive any of the rights as described in this Form, it | 4 | | shall not constitute a basis to revoke this Final and | 5 | | Irrevocable Consent. | 6 | | That I do hereby consent and agree to the adoption of such | 7 | | child.
| 8 | | That I wish to and understand that by signing this consent | 9 | | I do
irrevocably and permanently give up all custody and other | 10 | | parental
rights I have to such child.
| 11 | | That I understand such child will be placed for adoption | 12 | | and that I
cannot under any circumstances, after signing this | 13 | | document, change my
mind and revoke or cancel this consent or | 14 | | obtain or recover custody or
any other rights over such child. | 15 | | That I have read and understand the
above and I am signing it | 16 | | as my free and voluntary act.
| 17 | | Dated (insert date).
| 18 | | .........................
| 19 | | If under Section 8 the consent of more than one person is | 20 | | required,
then each such person shall execute a separate | 21 | | consent.
| 22 | | A-1. (1) The form of the Final and Irrevocable Consent to | 23 | | Adoption by a Specified Person or Persons: Non-DCFS Case set | 24 | | forth in this subsection A-1 is to be used by legal parents | 25 | | only. This form is not to be used in cases in which there is a |
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| 1 | | pending petition under Section 2-13 of the Juvenile Court Act | 2 | | of 1987. | 3 | | (2) The form of the Final and Irrevocable Consent to | 4 | | Adoption by a Specified Person or Persons in a non-DCFS case | 5 | | shall have the caption of the proceeding in which it is to be | 6 | | filed and shall be substantially as follows: | 7 | | FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY | 8 | | A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE | 9 | | I, ...., (relationship, e.g., mother, father) of ...., a | 10 | | .. male or female (circle one) child, state: | 11 | | 1. That such child was born on ...., at ....., in the | 12 | | City /Town of ... and State of .... | 13 | | 2. That I reside at ...., County of .... and State of .... , | 14 | | my email address (if I have one) is .... my cell phone number | 15 | | where I can receive text messages (if I have one) is .... and | 16 | | my land line phone number (if I have one) is ...., and any | 17 | | other contact information is .... | 18 | | 3. That I am of the age of .... years. | 19 | | 4. That I hereby enter my appearance in this proceeding and | 20 | | waive service of summons on me. | 21 | | 5. That I hereby acknowledge that I have been provided a | 22 | | copy of the Birth Parent Rights and Responsibilities-Private | 23 | | Form before signing this Consent and that I have had time to | 24 | | read, or have had read to me, this Form and that I understand |
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| 1 | | the Rights and Responsibilities described in this Form. I | 2 | | understand that if I do not receive any of my rights as | 3 | | described in said Form, it shall not constitute a basis to | 4 | | revoke this Final and Irrevocable Consent to Adoption by a | 5 | | Specified Person. | 6 | | 6. That I do hereby consent and agree to the adoption of | 7 | | such child by .... (specified person or persons) only. If only | 8 | | first names are used for the specified person or persons, I | 9 | | voluntarily sign this specified consent form without | 10 | | disclosure to me of the last name of the specified person or | 11 | | persons. However, I understand that if I wish to know the last | 12 | | name of the specified person or persons, I may request it | 13 | | before signing the form. If I do not receive the last name, I | 14 | | may choose not to sign the specified consent form. | 15 | | 7. That I wish to and understand that upon signing this | 16 | | consent I do irrevocably and permanently give up all custody | 17 | | and other parental rights I have to such child if such child is | 18 | | adopted by .... (specified person or persons). I hereby | 19 | | transfer all of my rights to the custody, care and control of | 20 | | such child to ............................. (specified person | 21 | | or persons). | 22 | | 8. That I understand such child will be adopted by | 23 | | ....................... (specified person or persons) and that | 24 | | I cannot under any circumstances, after signing this document, | 25 | | change my mind and revoke or cancel this consent or obtain or | 26 | | recover custody or any other rights over such child if |
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| 1 | | ............................ (specified person or persons) | 2 | | adopt(s) such child; PROVIDED that each specified person has | 3 | | filed or shall file, within 60 days from the date hereof, a | 4 | | petition for the adoption of such child. | 5 | | 9. That if the specified person or persons designated | 6 | | herein do not file a petition for adoption within the | 7 | | time-frame specified above, or, if said petition for adoption | 8 | | is filed within the time-frame specified above but the adoption | 9 | | petition is dismissed with prejudice or the adoption proceeding | 10 | | is otherwise concluded without an order declaring the child to | 11 | | be the adopted child of the specified person or persons, then I | 12 | | understand that I will be sent receive written notice of such | 13 | | circumstances at the mailing address, at the email address, | 14 | | through a text message to my cell phone number, and to any | 15 | | other contact information I have provided in paragraph 2 within | 16 | | 5 10 business days of this their occurrence. I understand that | 17 | | the notice will be directed to me using the contact information | 18 | | I have provided in this consent. I understand that I will have | 19 | | 15 10 business days from the date that the written notice is | 20 | | sent to me to respond in the manner described in the notice , | 21 | | within which time I may request the Court to declare this | 22 | | consent voidable and return the child to me. I further | 23 | | understand that the Court will make the final decision of | 24 | | whether or not the child will be returned to me. If I do not | 25 | | make such request within 15 10 business days of the date of the | 26 | | notice was sent , then I expressly waive any other notice or |
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| 1 | | service of process in any legal proceeding regarding the child, | 2 | | including a legal proceeding for someone other than ..... | 3 | | (specified person or persons) to adopt for the adoption of the | 4 | | child , and that I will have no parental rights as to the child. | 5 | | The person sending the notice shall file an affidavit of notice | 6 | | as proof of the date sent . | 7 | | 10. That I expressly acknowledge that nothing in this | 8 | | Consent
impairs the validity and absolute finality of this
| 9 | | Consent under any circumstance other than those described in
| 10 | | paragraph 9 of this Consent. | 11 | | 11. That I understand that I have a remaining duty and
| 12 | | obligation to keep .............. (insert name and address of | 13 | | the attorney
for the specified person or persons) informed of | 14 | | my current
address or other preferred contact information until | 15 | | this adoption has been finalized. My failure to
do so may | 16 | | result in the termination of my parental rights and
the child | 17 | | being placed for adoption in another home. | 18 | | 12. That I do expressly waive any other notice or service | 19 | | of process in any of the legal proceedings for the adoption of | 20 | | the child as long as the adoption proceeding by the specified | 21 | | person or persons is pending. | 22 | | 13. That I have read and understand the above and I am | 23 | | signing it as my free and voluntary act. | 24 | | 14. That I acknowledge that this consent is valid even if | 25 | | the specified person or persons separate or divorce or one of | 26 | | the specified persons dies prior to the entry of the final |
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| 1 | | judgment for adoption. | 2 | | Dated (insert date). | 3 | | ............................................. | 4 | | Signature of parent. | 5 | | ............................................. | 6 | | Address of parent. | 7 | | ............................................. | 8 | | Phone number(s) of parent. | 9 | | ............................................. | 10 | | Personal email(s) of parent. | 11 | | ............................................. | 12 | | (3) The form of the certificate of acknowledgement for a | 13 | | Final and Irrevocable Consent for Adoption by a Specified | 14 | | Person or Persons: Non-DCFS Case shall be substantially as | 15 | | follows: | 16 | | STATE OF ..............)
| 17 | | ) SS.
| 18 | | COUNTY OF .............) | 19 | | I, .................... (Name of Judge or other person), | 20 | | ..................... (official title, name, and address), | 21 | | certify that ............., personally known to me to be the | 22 | | same person whose name is subscribed to the foregoing Final and | 23 | | Irrevocable Consent for Adoption by a Specified Person or | 24 | | Persons; non-DCFS case, appeared before me this day in person |
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| 1 | | and acknowledged that (she)(he) signed and delivered the | 2 | | consent as (her)(his) free and voluntary act, for the specified | 3 | | purpose. I am further satisfied that, before signing this | 4 | | Consent, ........ has read, or has had read to him or her, the | 5 | | Birth Parent Rights and Responsibilities-Private Form. | 6 | | A-2. Birth Parent Rights and Responsibilities-Private | 7 | | Form. The Birth Parent Rights and Responsibilities-Private | 8 | | Form must be read by, or have been read to, any person | 9 | | executing a Final and Irrevocable Consent to Adoption under | 10 | | subsection A, a Final and Irrevocable Consent to Adoption by a | 11 | | Specified Person or Persons: Non-DCFS Case under subsection | 12 | | A-1, or a Consent to Adoption of Unborn Child under subsection | 13 | | B prior to the execution of said Consent. The form of the Birth | 14 | | Parent Rights and Responsibilities-Private Form shall be | 15 | | substantially as follows: | 16 | | Birth Parent Rights and Responsibilities-Private Form | 17 | | THIS FORM DOES NOT CONSTITUTE LEGAL ADVICE. LEGAL ADVICE IS | 18 | | DEPENDENT ON THE SPECIFIC CIRCUMSTANCES OF EACH SITUATION AND | 19 | | JURISDICTION. THE INFORMATION IN THIS FORM CANNOT REPLACE THE | 20 | | ADVICE OF AN ATTORNEY LICENSED IN YOUR STATE. | 21 | | As a birth parent in the State of Illinois, you have the | 22 | | right: | 23 | | 1. To have your own attorney represent you. The prospective |
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| 1 | | adoptive parents may agree to pay for the cost of your attorney | 2 | | in a manner consistent with Illinois law, but they are not | 3 | | required to do so. | 4 | | 2. To be treated with dignity and respect at all times and | 5 | | to make decisions free from coercion and pressure. | 6 | | 3. To request to receive counseling before and after | 7 | | signing a Final and Irrevocable Consent to Adoption | 8 | | ("Consent"), a Final and Irrevocable Consent to Adoption by a | 9 | | Specified Person or Persons: Non-DCFS Case ("Specified | 10 | | Consent"), or a Consent to Adoption of Unborn Child ("Unborn | 11 | | Consent"). The prospective adoptive parents may agree to pay | 12 | | for the cost of counseling in a manner consistent with Illinois | 13 | | law, but they are not required to do so. | 14 | | 4. To ask to be involved in choosing your child's | 15 | | prospective adoptive parents and to ask to meet them. | 16 | | 5. To ask your child's prospective adoptive parents any | 17 | | questions that pertain to your decision to place your child | 18 | | with them. | 19 | | 6. To see your child before signing a Consent or Specified | 20 | | Consent if you are the custodial parent, and to request to see | 21 | | your child if you are not the custodial parent. | 22 | | 7. To request contact with your child and/or the child's | 23 | | prospective adoptive parents, with the understanding that any | 24 | | promises regarding contact with your child or receipt of | 25 | | information about the child after signing a Consent, Specified | 26 | | Consent, or Unborn Consent cannot be enforced under Illinois |
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| 1 | | law. | 2 | | 8. To receive copies of all documents that you sign and | 3 | | have those documents provided to you in your preferred | 4 | | language. | 5 | | 9. To request that your identifying information remain | 6 | | confidential, unless required otherwise by Illinois law or | 7 | | court order, and to voluntarily share your medical, background, | 8 | | and identifying information, including information on the | 9 | | original birth certificate of your child. This can be done | 10 | | through the Illinois Adoption Registry and Medical Information | 11 | | Exchange or through completing the Birth Parent Preference | 12 | | Form. Please visit http://dph.illinois.gov or | 13 | | www.newillinoisadoptionlaw.com. | 14 | | 10. To access the Confidential Intermediary Program which | 15 | | provides a way for a court appointed person to connect and/or | 16 | | exchange information between adoptees, adoptive parents and | 17 | | birth parents, and other biological family members, provided in | 18 | | most cases that mutual consent is given. Please visit | 19 | | www.ci-illinois.org or call (800) 526-9022(x29). | 20 | | 11. To work with an adoption agency or attorney of your | 21 | | choice, or change said agency or attorney, provided you | 22 | | promptly inform all of the parties currently involved. | 23 | | 12. To receive, upon request, a written list of any | 24 | | promised support, financial or otherwise, from your attorney or | 25 | | the attorney for your child's prospective adoptive parents. | 26 | | 13. To delay signing a Consent, Specified Consent, or |
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| 1 | | Unborn Consent if you are not ready to do so. | 2 | | 14. To decline to sign a Consent, Specified Consent, or | 3 | | Unborn Consent even if you have received financial support from | 4 | | the prospective adoptive parents. | 5 | | If you do not receive any of the rights described in this | 6 | | Form, it shall not be a basis to revoke a Consent, Specified | 7 | | Consent, or Unborn Consent. | 8 | | As a Birth Parent in the State of Illinois, you have the | 9 | | responsibility: | 10 | | 1. To carefully consider your reasons for choosing | 11 | | adoption. | 12 | | 2. (Birth mothers only) To accurately complete an Affidavit | 13 | | of Identification, which identifies the father of the child | 14 | | when known, with the understanding that a birth mother has a | 15 | | right to decline to identify the birth father. | 16 | | 3. To provide the necessary documentation regarding | 17 | | financial need to make an appropriate determination of | 18 | | reasonable pregnancy-related expenses. | 19 | | 4. To not accept financial support or reimbursement of | 20 | | pregnancy related expenses simultaneously from more than one | 21 | | source or if you are not pregnant, as doing so is a crime. | 22 | | 5. To voluntarily provide all known medical, background, | 23 | | and family information about yourself and your immediate family | 24 | | to your child's prospective adoptive parents or their attorney. | 25 | | For the health of your child, you are strongly encouraged, but | 26 | | not required, to do so as set forth on the following form: |
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| 1 | | Birth Parent Medical Information | 2 | | The purpose of this form is to gather your health history, | 3 | | genetic history, and social background information to share | 4 | | with the adoptive parents. It is important the adoptive family | 5 | | provide this information to the child's physician. It will | 6 | | become a part of the child's medical and family history. This | 7 | | form, in its entirety, will be given to the adoptive parent(s). | 8 | | The following information is true and complete to the best | 9 | | of my knowledge and belief. | 10 | | Birth parent name: | 11 | | ...................................... | 12 | | Signature: | 13 | | .............................................. | 14 | | Date: .................................................... | 15 | | YES or NO (circle one) I agree to release my full name on | 16 | | this form to the adoptive family. If NO is circled then the | 17 | | birth parent's name shall be redacted on this form. | 18 | | MOTHER'S PHYSICAL CHARACTERISTICS: | 19 | | Eyes: ... Hair: .... Complexion: .... Height: .... | 20 | | Weight: .... Body build: .....
Race: ..... | 21 | | Nationality/Descent: ....... Blood type: .... Rh factor: .... | 22 | | Eye glasses or contact lenses? Yes /.../ No /.../ | 23 | | Right /.../ Left /.../ handed | 24 | | Age: .... or Date of birth: ..... Religion: ................. | 25 | | Please list your highest education level, occupation, | 26 | | hobbies, interests, and talents: |
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| 1 | | ............................ | 2 | | Existence of any disabilities? Yes /.../ No /.../ | 3 | | If yes, explain: ............................................. | 4 | | If you have other children, list them below. Include any | 5 | | children previously placed for adoption. | 6 | | .................... | 7 | | Describe your relationship with the birth father: ....... | 8 | | FATHER'S PHYSICAL CHARACTERISTICS: | 9 | | Eyes: ... Hair: .... Complexion: .... Height: .... | 10 | | Weight: .... Body build: .....
Race: ..... | 11 | | Nationality/Descent: ....... Blood type: .... Rh factor: .... | 12 | | Eye glasses or contact lenses? Yes /.../ No /.../ | 13 | | Right /.../ Left /.../ handed | 14 | | Age: .... or Date of birth: ..... Religion: ................. | 15 | | Please list your highest education level, occupation, | 16 | | hobbies, interests, and talents: | 17 | | ............................ | 18 | | Existence of any disabilities? Yes /.../ No /.../ | 19 | | If yes, explain: ............................................. | 20 | | If you have other children, list them below. Include any | 21 | | children previously placed for adoption. | 22 | | .................... | 23 | | PREGNANCY HISTORY INVOLVING THIS CHILD | 24 | | Month prenatal care began during this pregnancy: ......... | 25 | | Complications during pregnancy: Yes ... No ... If yes, | 26 | | explain: .................................................... |
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| 1 | | ............................................................. | 2 | | MEDICATION AND OTHER SUBSTANCES USED DURING | 3 | | PREGNANCY OR YEAR PRIOR TO PREGNANCY | |
4 | | | | | FREQUENCY/ | FREQUENCY/ | |
5 | | | | | AMOUNT | AMOUNT | |
6 | | | | | DURING | PRIOR TO | |
7 | | | YES | NO | PREGNANCY | PREGNANCY | |
8 | | Alcohol | /../ | /../ | ................. | ............... | |
9 | | Amphetamines | /../ | /../ | ................. | ............... | |
10 | | Barbiturates | /../ | /../ | ................. | ............... | |
11 | | Cocaine | /../ | /../ | ................. | ............... | |
12 | | Heroin | /../ | /../ | ................. | ............... | |
13 | | LSD | /../ | /../ | ................. | ............... | |
14 | | Marijuana | /../ | /../ | ................. | ............... | |
15 | | Caffeine | | | | | |
16 | | (Coffee, | | | | | |
17 | | tea, etc) | /../ | /../ | ................. | ............... | |
18 | | Prescription | | | | | |
19 | | drugs | /../ | /../ | ................. | ............... | |
20 | | Non- | | | | | |
21 | | prescription | | | | | |
22 | | drugs | /../ | /../ | ................. | ............... | |
23 | | Other | /../ | /../ | ................. | ............... |
| 24 | | In addition to this form, a birth parent shall also be | 25 | | provided the forms for the Illinois Adoption Registry and |
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| 1 | | Medical Information Exchange. | 2 | | B. The form of consent required for the adoption of an | 3 | | unborn child
shall be substantially as follows:
| 4 | | CONSENT TO ADOPTION OF UNBORN CHILD
| 5 | | I, ...., state:
| 6 | | That I am the father of a child expected to be born on or | 7 | | about ....
to .... (name of mother).
| 8 | | That I reside at .... County of ...., and State of .....
| 9 | | That I am of the age of .... years.
| 10 | | That I hereby enter my appearance in such adoption | 11 | | proceeding and
waive service of summons on me.
| 12 | | That I hereby acknowledge that I have been provided with a | 13 | | copy of the Birth Parent Rights and Responsibilities-Private | 14 | | Form before signing this Consent, and that I have had time to | 15 | | read, or have had read to me, this Form. I understand that if I | 16 | | do not receive any of the rights as described in this Form, it | 17 | | shall not constitute a basis to revoke this Consent to Adoption | 18 | | of Unborn Child. | 19 | | That I do hereby consent and agree to the adoption of such | 20 | | child, and
that I have not previously executed a consent or | 21 | | surrender with respect
to such child.
| 22 | | That I wish to and do understand that by signing this | 23 | | consent I do
irrevocably and permanently give up all custody | 24 | | and other parental
rights I have to such child, except that I |
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| 1 | | have the right to revoke this
consent by giving written notice | 2 | | of my revocation not later than 72
hours after the birth of the | 3 | | child.
| 4 | | That I understand such child will be placed for adoption | 5 | | and that,
except as hereinabove provided, I cannot under any | 6 | | circumstances, after
signing this document, change my mind and | 7 | | revoke or cancel this consent
or obtain or recover custody or | 8 | | any other rights over such child.
| 9 | | That I have read and understand the above and I am signing | 10 | | it as my
free and voluntary act.
| 11 | | Dated (insert date).
| 12 | | ........................
| 13 | | B-5. (1) The parent of a child may execute a consent to | 14 | | standby
adoption by a specified person or persons. A consent | 15 | | under this subsection B-5
shall be acknowledged by a parent | 16 | | pursuant to subsection H and subsection K of
this Section.
The | 17 | | form of consent required for the standby adoption of a born | 18 | | child
effective at a future date when the consenting
parent of | 19 | | the child dies or
requests that a final judgment of adoption be | 20 | | entered shall be substantially as
follows:
| 21 | | FINAL AND IRREVOCABLE CONSENT
| 22 | | TO STANDBY ADOPTION
| 23 | | I, ..., (relationship, e.g. mother or father)
of ...., a |
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| 1 | | .. male or female (circle one) child, state:
| 2 | | That the child was born on .... at .....
| 3 | | That I reside at ...., County of ...., and State of .....
| 4 | | That I am of the age of .... years.
| 5 | | That I hereby enter my appearance in this proceeding and | 6 | | waive service of
summons on me in this action only.
| 7 | | That I do hereby consent and
agree to the standby adoption | 8 | | of the child, and that I have not previously
executed a consent | 9 | | or surrender with respect to the child.
| 10 | | That I wish to and understand that by signing this consent | 11 | | I do irrevocably
and permanently give up all custody and other | 12 | | parental rights I have to the
child, effective upon
(my death) | 13 | | (the child's other parent's death) or upon (my) (the other
| 14 | | parent's) request for the entry of a final judgment for | 15 | | adoption if .....
(specified person or persons) adopt my child.
| 16 | | That I understand that until (I die) (the child's other | 17 | | parent dies), I
retain all legal rights and obligations | 18 | | concerning the child, but at that time,
I irrevocably give all | 19 | | custody and other parental rights to .... (specified
person or | 20 | | persons).
| 21 | | I understand my child will be adopted by ....... (specified | 22 | | person or
persons) only and that I cannot, under any | 23 | | circumstances, after signing this
document, change my mind and | 24 | | revoke or cancel this consent or obtain or recover
custody or | 25 | | any other rights over my child if ..... (specified person or
| 26 | | persons) adopt my child.
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| 1 | | I understand that this consent to standby adoption is valid | 2 | | only if the
petition for standby adoption is filed and that if | 3 | | ....... (specified person or
persons), for any reason, cannot | 4 | | or will not file a petition for standby
adoption or if his, | 5 | | her, or their petition for standby adoption is denied, then
| 6 | | this consent is void. I have the right to notice of any other | 7 | | proceeding that
could affect my parental rights.
| 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 | | If under Section 8 the consent of more than one person is | 13 | | required, then each
such
person shall execute a separate | 14 | | consent. A separate consent shall be executed
for each
child.
| 15 | | (2) If the parent consents to a standby adoption by 2 | 16 | | specified persons,
then the form shall contain 2 additional | 17 | | paragraphs in substantially the
following form:
| 18 | | If .... (specified persons) obtain a judgment of
| 19 | | dissolution of
marriage before the judgment for adoption is | 20 | | entered, then .....
(specified person) shall adopt my child. I | 21 | | understand that I cannot change my
mind and revoke this consent | 22 | | or obtain or recover custody of my child if .....
(specified | 23 | | persons) obtain a judgment of dissolution of marriage and .....
| 24 | | (specified person) adopts my child. I understand that I cannot | 25 | | change my
mind and revoke this consent if ...... (specified |
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| 1 | | persons) obtain a
judgment of dissolution of marriage before | 2 | | the adoption is final. I
understand that this consent to | 3 | | adoption has no effect on who will get custody
of my child if | 4 | | ..... (specified persons) obtain a judgment of dissolution
of | 5 | | marriage after the adoption is final. I understand that if | 6 | | either .....
(specified persons) dies before the petition to | 7 | | adopt my child is granted, then
the surviving person may adopt | 8 | | my child. I understand that I cannot change my
mind and revoke | 9 | | this consent or obtain or recover custody of my child if the
| 10 | | surviving person adopts my child.
| 11 | | A consent to standby adoption by specified persons on this | 12 | | form shall have no
effect on a court's determination of custody | 13 | | or visitation under the Illinois
Marriage and Dissolution
of | 14 | | Marriage Act if the marriage of the specified persons is | 15 | | dissolved before
the adoption is final.
| 16 | | (3) The form of the certificate of acknowledgement for a | 17 | | Final and
Irrevocable Consent for Standby Adoption shall be | 18 | | substantially as follows:
| 19 | | STATE OF .....)
| 20 | | ) SS.
| 21 | | COUNTY OF ....)
| 22 | | I, ....... (name of Judge or other person) ..... (official | 23 | | title,
name, and address), certify that ......., personally | 24 | | known to me to be
the same person whose name is subscribed to |
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| 1 | | the foregoing Final and Irrevocable
Consent to Standby | 2 | | Adoption, appeared before me this day in person and
| 3 | | acknowledged that (she) (he) signed and
delivered the consent | 4 | | as (her) (his) free and voluntary act, for the specified
| 5 | | purpose.
| 6 | | I have fully explained that this consent to adoption is | 7 | | valid only if the
petition to adopt is filed, and that if the | 8 | | specified person or persons, for
any reason, cannot or will not | 9 | | adopt the child or if the adoption petition is
denied, then | 10 | | this consent will be void. I have fully explained that if the
| 11 | | specified person or persons adopt the child, by signing this | 12 | | consent (she) (he)
is irrevocably and permanently | 13 | | relinquishing all parental rights to the child,
and (she) (he) | 14 | | has stated that such is (her) (his) intention and desire.
| 15 | | Dated (insert date).
| 16 | | Signature ..............................
| 17 | | (4) If a consent to standby adoption is executed in this | 18 | | form,
the consent shall be valid only if the specified
person | 19 | | or persons adopt the child. The consent shall be void if:
| 20 | | (a) the specified person or persons do not file a | 21 | | petition for standby
adoption of the child; or
| 22 | | (b) a court denies the standby adoption petition.
| 23 | | The parent shall not need to take further action to revoke | 24 | | the consent if the
standby adoption by the specified person or | 25 | | persons does not occur,
notwithstanding the provisions of |
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| 1 | | Section 11 of this Act.
| 2 | | C. The form of surrender to any agency given by a parent of | 3 | | a born
child who is to be subsequently placed for adoption | 4 | | shall be
substantially as follows and shall contain such other | 5 | | facts and
statements as the particular agency shall require.
| 6 | | FINAL AND IRREVOCABLE SURRENDER
| 7 | | FOR PURPOSES OF ADOPTION
| 8 | | I, .... (relationship, e.g., mother, father, relative, | 9 | | guardian) of
...., a .. male or female (circle one) child, | 10 | | state:
| 11 | | That such child was born on ...., at .....
| 12 | | That I reside at ...., County of ...., and State of .....
| 13 | | That I am of the age of .... years.
| 14 | | That I do hereby surrender and entrust the entire custody | 15 | | and control
of such child to the .... (the "Agency"), a | 16 | | (public) (licensed) child
welfare agency with its principal | 17 | | office in the City of ...., County of
.... and State of ...., | 18 | | for the purpose of enabling it to care for and
supervise the | 19 | | care of such child, to place such child for adoption and
to | 20 | | consent to the legal adoption of such child.
| 21 | | That I hereby grant to the Agency full power and authority | 22 | | to place
such child with any person or persons it may in its | 23 | | sole discretion
select to become the adopting parent or parents | 24 | | and to consent to the
legal adoption of such child by such |
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| 1 | | person or persons; and to take any
and all measures which, in | 2 | | the judgment of the Agency, may be for the
best interests of | 3 | | such child, including authorizing medical, surgical
and dental | 4 | | care and treatment including inoculation and anaesthesia for
| 5 | | such child.
| 6 | | That I wish to and understand that by signing this | 7 | | surrender I do
irrevocably and permanently give up all custody | 8 | | and other parental
rights I have to such child.
| 9 | | That I understand I cannot under any circumstances, after | 10 | | signing
this surrender, change my mind and revoke or cancel | 11 | | this surrender or
obtain or recover custody or any other rights | 12 | | over such child.
| 13 | | That I have read and understand the above and I am signing | 14 | | it as my
free and voluntary act.
| 15 | | Dated (insert date).
| 16 | | ........................
| 17 | | C-5. The form of a Final and Irrevocable Designated | 18 | | Surrender for Purposes of Adoption to any agency given by a | 19 | | parent of a born child who is to be subsequently placed for | 20 | | adoption is to be used by legal parents only. The form shall be | 21 | | substantially as follows and shall contain such other facts and | 22 | | statements as the particular agency shall require: | 23 | | FINAL AND IRREVOCABLE DESIGNATED SURRENDER | 24 | | FOR PURPOSES OF ADOPTION |
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| 1 | | I, .... (relationship, e.g., mother, father, relative, | 2 | | guardian) of ...., a .. male or female (circle one) child, | 3 | | state: | 4 | | 1. That such child was born on ...., at ..... | 5 | | 2. That I reside at ...., County of ...., and State of | 6 | | ..... , my email address (if I have one) is .... my cell phone | 7 | | number where I can receive text messages (if I have one) is | 8 | | .... and my land line phone number (if I have one) is ...., and | 9 | | any other contact information is .... | 10 | | 3. That I am of the age of .... years. | 11 | | 4. That I do hereby surrender and entrust the entire | 12 | | custody 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 with | 17 | | ............................. (specified person or persons) | 18 | | and to consent to the legal adoption of such child and to take | 19 | | any and all measures which, in the judgment of the Agency, may | 20 | | be for the best interests of such child, including authorizing | 21 | | medical, surgical and dental care and treatment including | 22 | | inoculation and anesthesia for such child. If only first names | 23 | | are used for the specified person or persons, I voluntarily | 24 | | sign this designated surrender without disclosure to me of the | 25 | | last name of the specified person or persons. However, I |
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| 1 | | understand that if I wish to know the last name of the | 2 | | specified person or persons, I may request it before signing | 3 | | the form. If I do not receive the last name, I may choose not to | 4 | | sign the designated surrender form. | 5 | | 5. That I wish to and understand that by signing this | 6 | | surrender I do irrevocably and permanently give up all custody | 7 | | and other parental rights I have to such child. | 8 | | 6. That if the petition for adoption is not filed by the
| 9 | | specified person or persons designated herein or, if the
| 10 | | petition for adoption is filed but the adoption petition is
| 11 | | dismissed with prejudice or the adoption proceeding is
| 12 | | otherwise concluded without an order declaring the child to be
| 13 | | the adopted child of each specified person, then I understand | 14 | | that the Agency will send provide notice to me at the mailing | 15 | | address, at the email address, through a text message to my | 16 | | cell phone number provided in paragraph 2, and to any other | 17 | | contact information I have provided in paragraph 2 within 5 10 | 18 | | business days of this occurrence. The person sending the notice | 19 | | shall prepare an affidavit of notice and that such notice will | 20 | | be directed to me using the contact information I have provided | 21 | | to the Agency . I understand that I will have 15 10 business | 22 | | days from the date that the written notice was sent that the | 23 | | Agency sends me its notice to respond, within which time I may | 24 | | choose to designate other adoptive parent(s). However, I | 25 | | acknowledge that
the Agency has full power and authority to | 26 | | place the child for adoption with
any person or persons it may |
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| 1 | | in its sole discretion select to
become the adopting parent or | 2 | | parents and to consent to the
legal adoption of the child by | 3 | | such person or persons. | 4 | | 7. That I acknowledge that this surrender is valid even if | 5 | | the specified persons separate or divorce or one of the | 6 | | specified persons dies prior to the entry of the final judgment | 7 | | for adoption. | 8 | | 8. That I expressly acknowledge that the above paragraphs 6 | 9 | | and 7 do not impair the validity and absolute finality of this | 10 | | surrender under any circumstance. | 11 | | 9. That I understand that I have a remaining obligation to | 12 | | keep the Agency informed of my current contact information | 13 | | until the adoption of the child has been finalized if I wish to | 14 | | be notified in the event the adoption by the specified | 15 | | person(s) cannot proceed. | 16 | | 10. That I understand I cannot under any circumstances, | 17 | | after signing this surrender, change my mind and revoke or | 18 | | cancel this surrender or obtain or recover custody or any other | 19 | | rights over such child. | 20 | | 11. That I have read and understand the above and I am | 21 | | signing it as my free and voluntary act. | 22 | | Dated (insert date). | 23 | | .............................. | 24 | | D. The form of surrender to an agency given by a parent of | 25 | | an unborn
child who is to be subsequently placed for adoption |
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| 1 | | shall be
substantially as follows and shall contain such other | 2 | | facts and
statements as the particular agency shall require.
| 3 | | SURRENDER OF UNBORN CHILD FOR
| 4 | | PURPOSES OF ADOPTION
| 5 | | I, .... (father), state:
| 6 | | That I am the father of a child expected to be born on or | 7 | | about ....
to .... (name of mother).
| 8 | | That I reside at ...., County of ...., and State of .....
| 9 | | That I am of the age of .... years.
| 10 | | That I do hereby surrender and entrust the entire custody | 11 | | and control
of such child to the .... (the "Agency"), a | 12 | | (public) (licensed) child
welfare agency with its principal | 13 | | office in the City of ...., County of
.... and State of ...., | 14 | | for the purpose of enabling it to care for and
supervise the | 15 | | care of such child, to place such child for adoption and
to | 16 | | consent to the legal adoption of such child, and that I have | 17 | | not
previously executed a consent or surrender with respect to | 18 | | such child.
| 19 | | That I hereby grant to the Agency full power and authority | 20 | | to place
such child with any person or persons it may in its | 21 | | sole discretion
select to become the adopting parent or parents | 22 | | and to consent to the
legal adoption of such child by such | 23 | | person or persons; and to take any
and all measures which, in | 24 | | the judgment of the Agency, may be for the
best interests of |
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| 1 | | such child, including authorizing medical, surgical
and dental | 2 | | care and treatment, including inoculation and anaesthesia for
| 3 | | such child.
| 4 | | That I wish to and understand that by signing this | 5 | | surrender I do
irrevocably and permanently give up all custody | 6 | | and other parental
rights I have to such child.
| 7 | | That I understand I cannot under any circumstances, after | 8 | | signing
this surrender, change my mind and revoke or cancel | 9 | | this surrender or
obtain or recover custody or any other rights | 10 | | over such child, except
that I have the right to revoke this | 11 | | surrender by giving written notice
of my revocation not later | 12 | | than 72 hours after the birth of such child.
| 13 | | That I have read and understand the above and I am signing | 14 | | it as my
free and voluntary act.
| 15 | | Dated (insert date).
| 16 | | ........................
| 17 | | E. The form of consent required from the parents for the | 18 | | adoption of
an adult, when such adult elects to obtain such | 19 | | consent, shall be
substantially as follows:
| 20 | | CONSENT
| 21 | | I, ...., (father) (mother) of ...., an adult, state:
| 22 | | That I reside at ...., County of .... and State of .....
| 23 | | That I do hereby consent and agree to the adoption of such |
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| 1 | | adult by
.... and .....
| 2 | | Dated (insert date).
| 3 | | .........................
| 4 | | F. The form of consent required for the adoption of a child | 5 | | of the
age of 14 years or over, or of an adult, to be given by | 6 | | such person,
shall be substantially as follows:
| 7 | | CONSENT
| 8 | | I, ...., state:
| 9 | | That I reside at ...., County of .... and State of ..... | 10 | | That I am
of the age of .... years. That I hereby enter my | 11 | | appearance in this proceeding and waive service of summons on | 12 | | me. That I consent and agree to my adoption by
.... and .....
| 13 | | Dated (insert date).
| 14 | | ........................
| 15 | | G. The form of consent given by an agency to the adoption | 16 | | by
specified persons of a child previously surrendered to it | 17 | | shall set
forth that the agency has the authority to execute | 18 | | such consent. The
form of consent given by a guardian of the | 19 | | person of a child sought to
be adopted, appointed by a court of | 20 | | competent jurisdiction, shall set
forth the facts of such | 21 | | appointment and the authority of the guardian to
execute such | 22 | | consent.
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| 1 | | H. A consent (other than that given by an agency, or | 2 | | guardian of the
person of the child sought to be adopted who | 3 | | was appointed by a court of
competent jurisdiction) shall be | 4 | | acknowledged by a parent before a judge of a court of competent | 5 | | jurisdiction or, except as otherwise provided in
this Act, | 6 | | before a representative of an agency, or before a person, other | 7 | | than the attorney for the prospective adoptive parent or | 8 | | parents, designated by a court of competent
jurisdiction.
| 9 | | I. A surrender, or any other document equivalent to a | 10 | | surrender, by
which a child is surrendered to an agency shall | 11 | | be acknowledged by the
person signing such surrender, or other | 12 | | document, before a judge of a court of competent jurisdiction, | 13 | | or, except as otherwise provided in this Act, before a | 14 | | representative of an agency, or before a person designated by a | 15 | | court
of competent jurisdiction.
| 16 | | J. The form of the certificate of acknowledgment for a | 17 | | consent, a
surrender, or any other document equivalent to a | 18 | | surrender, shall be
substantially as follows:
| 19 | | STATE OF ....)
| 20 | | ) SS.
| 21 | | COUNTY OF ...)
| 22 | | I, .... (Name of judge or other person), .... (official | 23 | | title, name and
location of court or status or position of | 24 | | other person),
certify that ...., personally known to me to be | 25 | | the same person whose
name is subscribed to the foregoing |
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| 1 | | (consent) (surrender), appeared
before me this day in person | 2 | | and acknowledged that (she) (he) signed and
delivered such | 3 | | (consent) (surrender) as (her) (his) free and voluntary
act, | 4 | | for the specified purpose.
| 5 | | I have fully explained that by signing such (consent) | 6 | | (surrender)
(she) (he) is irrevocably relinquishing all | 7 | | parental rights to such
child or adult and (she) (he) has | 8 | | stated that such is (her) (his)
intention and desire. (Add if | 9 | | Consent only) I am further satisfied that, before signing this | 10 | | Consent, ........ has read, or has had read to him or her, the | 11 | | Birth Parent Rights and Responsibilities-Private Form.
| 12 | | Dated (insert date).
| 13 | | Signature ...............
| 14 | | K. When the execution of a consent or a surrender is | 15 | | acknowledged
before someone other than a judge,
such other | 16 | | person shall have his or her signature on the certificate
| 17 | | acknowledged before a notary public, in form substantially as | 18 | | follows:
| 19 | | STATE OF ....)
| 20 | | ) SS.
| 21 | | COUNTY OF ...)
| 22 | | I, a Notary Public, in and for the County of ......, in the | 23 | | State of
......, certify that ...., personally known to me to | 24 | | be the
same person whose name is subscribed to the foregoing |
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| 1 | | certificate of
acknowledgment, appeared before me in person and | 2 | | acknowledged that (she)
(he) signed such certificate as (her) | 3 | | (his) free and voluntary act and
that the statements made in | 4 | | the certificate are true.
| 5 | | Dated (insert date).
| 6 | | Signature ...................... Notary Public
| 7 | | (official seal)
| 8 | | There shall be attached a certificate of magistracy, or | 9 | | other
comparable proof of office of the notary public | 10 | | satisfactory to the
court, to a consent signed and acknowledged | 11 | | in another state.
| 12 | | L. A surrender or consent executed and acknowledged outside | 13 | | of this
State, either in accordance with the law of this State | 14 | | or in accordance
with the law of the place where executed, is | 15 | | valid.
| 16 | | M. Where a consent or a surrender is signed in a foreign | 17 | | country,
the execution of such consent shall be acknowledged or | 18 | | affirmed in a
manner conformable to the law and procedure of | 19 | | such country.
| 20 | | N. If the person signing a consent or surrender is in the | 21 | | military
service of the United States, the execution of such | 22 | | consent or surrender
may be acknowledged before a commissioned | 23 | | officer and the signature of
such officer on such certificate | 24 | | shall be verified or acknowledged
before a notary public or by | 25 | | such other procedure as is then in effect
for such division or |
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| 1 | | branch of the armed forces.
| 2 | | O. (1) The parent or parents of a child in whose interests | 3 | | a petition
under Section 2-13 of the Juvenile Court Act of 1987 | 4 | | is pending may, with the
approval of the designated | 5 | | representative of the Department of Children and
Family | 6 | | Services ("Department" or "DCFS"), execute a consent to | 7 | | adoption by a specified person or
persons:
| 8 | | (a) in whose physical custody the child has resided for | 9 | | at least 6
months;
or
| 10 | | (b) in whose physical custody at least one sibling of | 11 | | the child who is the
subject of this consent has resided | 12 | | for at least 6 months, and
the child who is
the subject of | 13 | | this consent is currently residing in this foster home; or
| 14 | | (c) in whose physical custody a child under one year of | 15 | | age has resided
for at least 3 months.
| 16 | | The court may waive the time frames in subdivisions (a), | 17 | | (b), and (c) for good cause shown if the court finds it to be in | 18 | | the child's best interests. | 19 | | A consent under this subsection O shall be acknowledged by | 20 | | a parent pursuant to
subsection H and subsection K of this | 21 | | Section.
| 22 | | (2) The final and irrevocable consent to adoption by a | 23 | | specified person or persons in a Department of Children and | 24 | | Family Services (DCFS) case shall be substantially
as follows:
| 25 | | FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
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| 1 | | A SPECIFIED PERSON OR PERSONS: DCFS CASE
| 2 | | I, ......................................, the | 3 | | .................. ( mother or
father (circle one ) of a .... male | 4 | | or female (circle one) child, state:
| 5 | | 1. My child ............................ (name of | 6 | | child) was born on .....
(insert date) at | 7 | | .................... Hospital in the City/Town | 8 | | municipality of ........., in
................ County, | 9 | | State of ...............
| 10 | | 2. I reside at ......................, County of | 11 | | ............. and
State of .............. | 12 | | Mail may also be sent to me at this address | 13 | | ............................, in care of ................. | 14 | | My home telephone number is ...................... | 15 | | My cell telephone number is ...................... | 16 | | My e-mail address is .................................
| 17 | | 3. I, ..........................., am .... years old.
| 18 | | 4. I enter my appearance in this action for my child to | 19 | | be adopted by the
person or persons specified herein by me | 20 | | and waive service of
summons on me in this action only.
| 21 | | 5. I hereby acknowledge that I have been provided a | 22 | | copy of the Birth Parent Rights and Responsibilities in | 23 | | Illinois for Final and Irrevocable Consents to Adoption by | 24 | | a Specified Person or Persons for DCFS Cases before signing | 25 | | this Consent and that I have had time to read this form or |
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| 1 | | have it read to me and that I understand the rights and | 2 | | responsibilities described in this form. I understand that | 3 | | if I do not receive any of my rights as described in the | 4 | | form, it shall not constitute a basis to revoke this Final | 5 | | and Irrevocable Consent to Adoption by a Specified Person | 6 | | or Persons. | 7 | | 6. I do hereby consent and agree to the adoption of | 8 | | such child by .......... (names of current foster parent(s) | 9 | | or caregiver(s), hereinafter referred to as the | 10 | | " ( specified person or persons " ) only. | 11 | | 7. I wish to sign this consent and I understand that by | 12 | | signing this consent I irrevocably and permanently give up | 13 | | all my parental rights I have to my child. | 14 | | 8. I understand that this consent allows my child to be | 15 | | adopted by the specified person or persons .......... only | 16 | | and that I cannot under any circumstances after signing | 17 | | this document change my mind and revoke or cancel this | 18 | | consent. | 19 | | 9. I understand that this consent will be void if: | 20 | | (a) the Department places my child with someone | 21 | | other than the specified person or persons; or | 22 | | (b) a court denies the adoption petition for the | 23 | | specified person or persons to adopt my child; or | 24 | | (c) the DCFS Guardianship Administrator refuses to | 25 | | consent to my child's adoption by the specified person | 26 | | or persons on the basis that the adoption is not in my |
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| 1 | | child's best interests. | 2 | | I understand that if this consent is void I have | 3 | | parental rights to my child, subject to any applicable | 4 | | court orders including those entered under Article II of | 5 | | the Juvenile Court Act of 1987, unless and until I sign a | 6 | | new consent or surrender or my parental rights are | 7 | | involuntarily terminated. I understand that if this | 8 | | consent is void, my child may be adopted by someone other | 9 | | than the specified person or persons only if I sign a new | 10 | | consent or surrender, or my parental rights are | 11 | | involuntarily terminated. I understand that if this | 12 | | consent is void, the Department will notify me within 30 | 13 | | days using the addresses and telephone numbers I provided | 14 | | in paragraph 2 of this form. I understand that if I receive | 15 | | such a notice, it is very important that I contact the | 16 | | Department immediately, and preferably within 30 days, to | 17 | | have input into the plan for my child's future. | 18 | | 10. I understand that if a petition for adoption of my | 19 | | child is filed by someone other than the specified person | 20 | | or persons, the Department will notify me within 14 days | 21 | | after the Department becomes aware of the petition. The | 22 | | fact that someone other than the specified person or | 23 | | persons files a petition to adopt my child does not make | 24 | | this consent void. | 25 | | 11. If a person other than the specified person or | 26 | | persons files a petition to adopt my child or if the |
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| 1 | | consent is void under paragraph 9, the Department will send | 2 | | written notice to me using the mailing address and email | 3 | | address provided by me in paragraph 2 of this form. The | 4 | | Department will also contact me using the telephone numbers | 5 | | I provided in paragraph 2 of this form. It is very | 6 | | important that I let the Department know if any of my | 7 | | contact information changes. If I do not let the Department | 8 | | know if any of my contact information changes, I understand | 9 | | that I may not receive notification from the Department if | 10 | | this consent is void or if someone other than the specified | 11 | | person or persons files a petition to adopt my child. If | 12 | | any of my contact information changes, I should immediately | 13 | | notify: | 14 | | Caseworker's name and telephone number: | 15 | | ............................................................; | 16 | | Agency name, address, zip code, and telephone number: | 17 | | ............................................................; | 18 | | Supervisor's name and telephone number: | 19 | | ............................................................; | 20 | | DCFS Advocacy Office for Children and Families: | 21 | | 800-232-3798. | 22 | | 12. I expressly acknowledge that paragraph 9 (and | 23 | | paragraphs 8a and 8b, if applicable) do not impair the | 24 | | validity and finality of this consent under any | 25 | | circumstances.
| 26 | | 13. I have read and understand the above and I am |
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| 1 | | signing it as my free
and voluntary act.
| 2 | | Dated (insert date).
| 3 | | .............................................
| 4 | | Signature of parent
| 5 | | (3) If the parent consents to an adoption by 2 specified | 6 | | persons, then the
form shall contain 2 additional paragraphs in | 7 | | substantially the following form:
| 8 | | 8a. If ............... (specified persons) get a | 9 | | divorce
or are granted a dissolution of a civil union | 10 | | before the petition to adopt my child is granted, this | 11 | | consent is valid for ........... (specified person) to | 12 | | adopt my child. I understand that I cannot change my mind | 13 | | or revoke this consent or recover custody of my child on | 14 | | the basis that the specified persons divorce or are granted | 15 | | a dissolution of a civil union or that one of the specified | 16 | | persons has died .
| 17 | | 8b. I understand that if the specified persons get a | 18 | | divorce or are granted a dissolution of a civil union | 19 | | before the petition to adopt my child is granted, this | 20 | | consent remains valid only for either ............... | 21 | | (name only one specified person) to adopt my child
| 22 | | (specified persons) dies before the petition to adopt
my | 23 | | child is granted, this consent remains valid for the | 24 | | surviving person to adopt my child. I understand that I | 25 | | cannot change my mind or revoke this consent or recover |
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| 1 | | custody of my child on the basis that one of the specified | 2 | | persons dies .
| 3 | | 8c. I understand that if either of the specified | 4 | | persons dies before the petition to adopt my child is | 5 | | granted, this consent remains valid for the surviving | 6 | | person to adopt my child. | 7 | | (4) The form of the certificate of acknowledgement for a | 8 | | Final and
Irrevocable Consent for Adoption by a Specified | 9 | | Person or Persons: DCFS Case shall be
substantially as follows:
| 10 | | STATE OF ..............)
| 11 | | ) SS.
| 12 | | COUNTY OF .............)
| 13 | | I, .................... (Name of Judge or other person),
| 14 | | ..................... (official title, name, and address),
| 15 | | certify that ............., personally known to me to be the | 16 | | same person whose
name is subscribed to the foregoing Final and | 17 | | Irrevocable Consent for Adoption
by a Specified Person or | 18 | | Persons: DCFS Case, appeared before me this day
in person and | 19 | | acknowledged that (she)(he) signed and delivered the consent as
| 20 | | (her)(his) free and voluntary act, for the specified purpose.
| 21 | | I have fully explained that by signing this consent this | 22 | | parent is irrevocably
and permanently
relinquishing all | 23 | | parental rights to the child so that the child may be adopted | 24 | | by a specified person or persons, and this parent has stated |
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| 1 | | that
such is (her)(his) intention and desire. I have fully | 2 | | explained that this consent is void only if:
| 3 | | (a) the placement is disrupted and the child is moved | 4 | | to a different placement; or | 5 | | (b) a court denies the petition for adoption; or | 6 | | (c) the Department of Children and Family Services | 7 | | Guardianship Administrator refuses to consent to the | 8 | | child's adoption by a specified person or persons on the | 9 | | basis that the adoption is not in the child's best | 10 | | interests. | 11 | | Dated (insert date).
| 12 | | ...............................
| 13 | | Signature
| 14 | | (5) If a consent to adoption by a specified person or | 15 | | persons is executed in
this form, the following provisions | 16 | | shall apply. The consent shall be valid
only for the specified | 17 | | person or persons to adopt the child. The consent shall be void
| 18 | | if:
| 19 | | (a) the placement disrupts and the child is moved to | 20 | | another placement; or
| 21 | | (b) a court denies the petition for adoption; or
| 22 | | (c) the Department of Children and Family Services | 23 | | Guardianship
Administrator refuses to consent to the | 24 | | child's adoption by the specified person or persons on the | 25 | | basis that the adoption is not in the child's best |
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| 1 | | interests.
| 2 | | If the consent is void under this Section, the parent shall | 3 | | not need to take further action to revoke the consent. No | 4 | | proceeding for termination of parental rights shall be brought | 5 | | unless the parent who executed the consent to adoption by a | 6 | | specified person or persons has been notified of the | 7 | | proceedings pursuant to Section 7 of this Act or subsection (4) | 8 | | of Section 2-13 of the Juvenile Court Act of 1987.
| 9 | | (6) The Department of Children and Family Services is | 10 | | authorized
to promulgate rules necessary to implement this | 11 | | subsection O.
| 12 | | (7) (Blank).
| 13 | | (8) The Department of Children and Family Services shall | 14 | | promulgate a rule and procedures regarding Consents to Adoption | 15 | | by a Specified Person or Persons in DCFS cases. The rule and | 16 | | procedures shall provide for the development of the Birth | 17 | | Parent Rights and Responsibilities Form for DCFS
Cases. | 18 | | (9) A consent to adoption by specified persons on this
| 19 | | consent form shall have no effect on a court's determination of
| 20 | | custody or visitation under the Illinois Marriage and
| 21 | | Dissolution of Marriage Act or the Illinois Religious Freedom
| 22 | | Protection and Civil Union Act if the marriage or civil union | 23 | | of the
specified persons is dissolved after the adoption is | 24 | | final. | 25 | | P. If the person signing a consent is incarcerated or | 26 | | detained in a correctional facility, prison, jail, detention |
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| 1 | | center, or other comparable institution, either in this State | 2 | | or any other jurisdiction, the execution of such consent may be | 3 | | acknowledged before social service personnel of such | 4 | | institution, or before a person designated by a court of | 5 | | competent jurisdiction. | 6 | | Q. A consent may be acknowledged telephonically, via | 7 | | audiovisual connection, or other electronic means, provided | 8 | | that a court of competent jurisdiction has entered an order | 9 | | approving the execution of the consent in such manner and has | 10 | | designated an individual to be physically present with the | 11 | | parent executing such consent in order to verify the identity | 12 | | of the parent. | 13 | | R. An agency whose representative is acknowledging a | 14 | | consent pursuant to this Section shall be a public child | 15 | | welfare agency, or a child welfare agency, or a child placing | 16 | | agency that is authorized or licensed in the State or | 17 | | jurisdiction in which the consent is signed. | 18 | | S. The form of waiver by a putative or legal father of a | 19 | | born or unborn child shall be substantially as follows: | 20 | | FINAL AND IRREVOCABLE | 21 | | WAIVER OF PARENTAL RIGHTS OF PUTATIVE OR LEGAL FATHER | 22 | | I, .................... , state under oath or affirm as | 23 | | follows: | 24 | | 1. That the biological mother ............... has |
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| 1 | | named me as a possible biological or
legal father of her | 2 | | minor child who was born, or is expected to be born on
| 3 | | ..........., ......, in the City/Town of........., State | 4 | | of ........... | 5 | | 2. That I understand that the biological mother | 6 | | ............. intends to or has placed the child
for | 7 | | adoption. | 8 | | 3. That I reside at ................, in the City/Town | 9 | | of...........,
State of ................ | 10 | | 4. That I am ................ years of age and my date | 11 | | of birth is ..............., ............. | 12 | | 5. That I (select one): | 13 | | ..... am married to the biological mother. | 14 | | ..... am not married to the biological mother and | 15 | | have not been married to the biological
mother within | 16 | | 300 days before the child's birth or expected date of | 17 | | child's birth. | 18 | | ..... am not currently married to the biological | 19 | | mother, but was married to the biological
mother, | 20 | | within 300 days before the child's birth or expected | 21 | | date of child's birth. | 22 | | 6. That I (select one): | 23 | | ..... neither admit nor deny that I am the | 24 | | biological father of the child. | 25 | | ..... deny that I am the biological father of the | 26 | | child. |
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| 1 | | 7. That I hereby agree to the termination of my | 2 | | parental rights, if any, without further notice to me
of | 3 | | any proceeding for the adoption of the minor child, even if | 4 | | I have taken any action to establish
parental rights or | 5 | | take any such action in the future including registering | 6 | | with any putative father
registry. | 7 | | 8. That I understand that by signing this Waiver I do | 8 | | irrevocably and permanently give up all
custody and other | 9 | | parental rights I may have to such child. | 10 | | 9. That I understand that this Waiver is FINAL AND | 11 | | IRREVOCABLE and that I am permanently
barred from | 12 | | contesting any proceeding for the adoption of the child | 13 | | after I sign this Waiver. | 14 | | 10. That I waive any further service of summons or | 15 | | other pleadings in any proceeding to terminate
parental | 16 | | rights, if any to this child, or any proceeding for | 17 | | adoption of this child. | 18 | | 11. That I understand that if a final judgment or order | 19 | | of adoption for this child is not entered, then
any | 20 | | parental rights or responsibilities that I may have remain | 21 | | intact. | 22 | | 12. That I have read and understand the above and that | 23 | | I am signing it as my free and voluntary act. | 24 | | Dated: ................... , .............. | 25 | | ........................................... |
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| 1 | | Signature | 2 | | OATH | 3 | | I have been duly sworn and I state under oath that I have read | 4 | | and understood this Final and Irrevocable
Waiver of Parental | 5 | | Rights of Putative or Legal Father. The facts contained in it | 6 | | are true and correct to the
best of my knowledge. I have signed | 7 | | this document as my free and voluntary act in order to | 8 | | facilitate the
adoption of the child. | 9 | | .............................. | 10 | | Signature | 11 | | Signed and Sworn before me on | 12 | | this ............ day | 13 | | of ..........., 20.... | 14 | | ................... | 15 | | Notary Public | 16 | | (Source: P.A. 98-463, eff. 8-16-13; 99-833, eff. 1-1-17 .)
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