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Consent Of A Person Aged Fourteen Or Older CCCO 0004 - Illinois
| Consent Of A Person Aged Fourteen Or Older Form. This is a Illinois form and can be used in County Division Cook Local County . |
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Consent of a Person Aged Fourteen or Older (This form replaces CCO-12) (Rev. 3/21/13) CCCO 0004 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF _________________________________________________ and No. ___________________________ _________________________________________________ TO ADOPT: _________________________________________________ CONSENT OF A PERSON AGED FOURTEEN OR OLDER (2721) I, _____________________________________________________, state: 1. I reside at _____________________________________________________________________________, County of _______________________________, and State of _____________________________. 2. My age is ___________ years. 3. I consent and agree to my adoption by _____________________________________________________ and _____________________________________________________________________________________________. 4. I further consent and agree to the change of my name to __________________________________________ __________________________________________________________________________________________________________. 5. I hereby waive service of summons and enter my appearance in these proceedings. Dated: _________________________________, ________ ________________________________________________ (Signature) I, _________________________________________________, a Judge of the Circuit Court of Cook County, Illinois, do hereby certify that ______________________________________________________________, personally known to me to be the same person whose name is signed on the foregoing consent, and that s/he appeared before this day in person and acknowledged that s/he signed and delivered this consent as his/her free and voluntary act, for the purpose specified in it. In witness whereof, I have affixed my signature to this document on this _______________ day of ________________________________, _________ _________________________________________ Judge (COURT SEAL) Judge's No. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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