Consent Of A Parent Of Adoptee

Form A-2711 (Consent by parent of adoptee) Revision 5/2018 IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA ORPHANS222 COURT DIVISION IN RE: Adoption of : No. : ------------------------------------------------------------------------------------- : (Adoptee222s name exactly as it appears on birth certificate) CONSENT BY PARENT OF ADOPTEE TO THE HONORABLE, THE JUDGE OF SAID COURT: The following is hereby represented to the Court: 1.The full names (including complete middle name), ages, marital status and relationship of each parent to the above child are as follows: Name Age Marital Status Relationship (The identity of BOTH parents must be set forth above.) 2.This consent is executed more than 72 hours after the birth of said child (except that a putativefather) may execute a consent at any time after receiving notice of the expected or actual birth ofthe child.3.I hereby voluntarily and unconditionally consent to the adoption of said child.4.I understand that by signing this consent I indicate my intent to permanently give up all rights to thischild.5.I understand that such child will be placed for adoption.6.I understand I may revoke this consent to permanently give up all rights to this child by placing therevocation in writing and serving it upon the agency or adult to whom the child was relinquished.7.If I am the BIRTH father or putative father of the child, I understand that this consent to an adoptionis irrevocable unless I revoke it within 30 days after either the birth or my execution of the consent,whichever occurs later, by delivering a written revocation to: (insert the name and address of the agency coordinating the adoption) OR (insert the name and address of an attorney who represents the individual relinquishing parentalrights or prospective adoptive parent of the child) OR (insert the Court of the county in which the voluntary relinquishment form was or will be filed). (OVER THE CONTINUATION AND SIGNATURES) American LegalNet, Inc. www.FormsWorkFlow.com Form A-2711 (Consent by parent of adoptee) Revision 5/2018 8. If I am the BIRTH mother of the child, I understand that this consent to an adoption is irrevocable unless I revoke it within 30 days after executing it by delivering a written revocation to: (insert the name and address of the agency coordinating the adoption) OR (insert the name and address of an attorney who represents the individual relinquishing parental rights or prospective adoptive parent of the child) OR (insert the Court of the county in which the voluntary relinquishment form was or will be filed). 9. I have read and understand the above and I am signing it as a free and voluntary act. Signed this day of , 20, at o222clock .M. At in the presence of the two (place signed) witnesses whose signatures appear below. Print name of Consenting Parent Signature of Consenting Parent WITNESSES The undersigned two witnesses hereby certify that the above parent signed the above consent in our presence on the above date. Printed Name Address Relationship to Consenter Signature Signature JOINDER BY PARENTS OF MINOR CONSENTER The undersigned parents (or guardians) of the minor consenting parent who has not reached the age of 18 years, herby join in such consent, and make all the representations to the Court set forth in such consent. Date: Print Name Signature Print Name Signature American LegalNet, Inc. www.FormsWorkFlow.com NOTICE RE: ADOPTIONS. ANY CONSENT SIGNED OUTSIDE OF PA MUST COMPLY WITH THE LAWS OF THE STATE OR COUNTRY WHERE IT WAS SIGNED. SEE 23 PA.C.S.A 2472711(C). American LegalNet, Inc. www.FormsWorkFlow.com