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Statutory Consent Of Birth Parent - Pennsylvania
| Statutory Consent Of Birth Parent Form. This is a Pennsylvania form and can be used in Adoptions Orphans Court Chester Local County . |
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IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: {use initials only} Case Number: ___________________________ STATUTORY CONSENT OF BIRTH PARENT 1. [Name, age and marital status of consenter] 2. [Name, sex and birth date of child] 3. [Relationship of consenter to child] 4. [Name of other parent of child] I hereby voluntarily and named child. unconditionally consent to the adoption of the above I understand that by signing this consent I indicate my intent to permanently giv e up all rights to this child. I understand such child will be placed for adoption. I understand I may revoke this consent to permanently give up all rights to this child by placing the revocation in writing and serving it upon th e agency or adult to whom the child was relinquished. If I am the Birth Father or Putative Fa ther of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within thirty (30) days after either the birth of the child or my execution of the cons ent, whichever occur s later, by delivering a written revocation to [IN SERT THE NAME AND ADDRESS OF THE AGENCY COORDINATING THE ADOPTION] or [INSERT THE NAME AND ADDRESS OF AN ATTOR NEY WH O R EPRESENTS THE INDIVIDUAL RELINQUISHING PARENTAL RIGHTS OR PROSPECTIVE ADOPTIVE PARENT] or [INSERT THE COURT OF THE COUNTY IN WHICH THE VOLUNTARY RELINQUISHMENT FORM WAS OR WILL BE FILED]. If I am the Birth Mother of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within thirty (30) days after execut ing it by delivering a written revocation to [INSERT THE NA ME AND ADDRESS OF THE AGENCY COORDINATING THE ADOPTION] or [IN SERT THE NAME A ND ADDRESS OF A N ATTORNEY WHO REPRESENTS THE I NDIVIDUAL RE LINQUISHING PARENT AL American LegalNet, Inc. www.FormsWorkFlow.com RIGHTS OR PROSPECTIVE ADOPTIVE PAR ENT] or [INSERT THE CO URT OF T HE COUNTY IN WHICH THE VOLUNTARY RELINQUISHMENT FORM WAS OR WILL BE FILED]. act. I have read and understand the above and I am signing it as a free and volunt ary __________[SIGNATURE]_______ Type Name:____________________________ Date of Execution:____________________________ Place of Execution:____________________________ WITNESSES: (at least two) ________[SIGNATURE]__________ Type Name: Address: Relationship to Consenter: ________[SIGNATURE]__________ Type Name: Address: Relationship to Consenter: American LegalNet, Inc. www.FormsWorkFlow.com
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