STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS _______________________________________ _______________________________________ Petitioner VS. _______________________________________ _______________________________________ Defendant CASE NO.___________________ CONSENT TO ADOPTION OF UNBORN CHILD I,___________________________________________________________________________, state: That I am the father of a child expected to be born on or about__________________________, 20___, to______________________________________________________. (Name of Mother) That I reside at_______________________________________________________________________ County of ____________________________________________, and State of___________________________. That I am the age of _____________years. That I hereby enter my appearance in such adoption and waive service of summons on me. That I do hereby consent and agree to the adoption of such child, and that I have not previously executed a consent or surrender with respect to such child. That I wish to and do understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child, except that I have the right to revoke this consent by giving written notice of my revocation not later than 72 hours after the birth of the child. That I understand such child will be placed for adoption and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over such child. That I have read and understand the above and I am signing it as my free and voluntary act. Dated______________________________, 20____ _________________________________________ 2000 © American LegalNet, Inc. STATE OF ILLINOIS) ) SS COUNTY OF WILL ) I,_______________________________________________________________________, do hereby certify (Name and Official Title) that______________________________________________________________________________________ personally known to me to be the same person whose name is subscribed to the foregoing consent, appeared before me this day in person and acknowledged that he signed and delivered such consent as his free and voluntary act, for the specified purpose. I have fully explained that by signing such consent he is irrevocably relinquishing all parental rights to such child or adult and he has stated that such is his intention and desire. Witness,_________________________________, 20____ _______________________________________________ STATE OF ILLINOIS) ) SS COUNTY OF WILL ) I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that _______________ ______________________________, personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me in person and acknowledged that he signed such certificate as his free and voluntary act and that the statements made in said certificate are true. Signed and sworn to before me ________________________________________, 20____ (Official Seal) _______________________________________________ (Notary Public) 2000 © American LegalNet, Inc.