Consent To Adoption Of Minor Child
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5K.S.A. 59-2129
Consent to Adoption
(7/1/05)
CONSENT TO ADOPTION OF MINOR CHILD
__________
NOTICE TO PARENT OR LEGAL GUARDIAN:
This is an important legal document and by signing it you are permanently giving up
all custody and other parental rights to the child named herein, so as to permit the
child's adoption. You are to receive a copy of this document.
1.
I, __________, (mother, father, legal guardian) of _________________, a minor
child, state:
2.
The child was born on
at
at _____ ___.m.
(date of birth)
(place of birth)
3.
I reside at________________, county of __________ and state of __________.
[My social security number is
.]
4.
I am of the age of
years and was born on
.
5.
I do hereby consent and agree to the adoption of the child [by ______________]
[and I do not require disclosure of the name or other identification of the adopting
parent or parents].
6.
I wish to and understand that by signing this consent I do permanently give up all
custody and other parental rights I have to the child.
7.
[I am of sound mind and under no undue restraint or duress.] I have read and
understand the above and I am signing it as my free and voluntary act.
8.
[I was married to
at the time of the child’s
(conception)(birth) and he is the father of the child. His present address is
.]
9.
[I was not married at the time the child was conceived or born. The father of the
child is
, whose present address is
.]
[There are no other possible putative fathers.] [
was
determined to be the child’s father in
District Court, case number
.]
10.
[Neither the child nor I am a member of an Indian tribe recognized by federal law
nor an Alaskan Native recognized by federal law.] [I am a member of the
tribe,
]. [The child is a member of the
(address)
tribe,
.]
(address)
11.
I hereby freely and voluntarily enter my appearance in any proceeding instituted
in any court of competent jurisdiction for the adoption of the child and waive notice of all
proceedings of the adoption.
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