STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS ___________________________________________ ___________________________________________ Petitioner VS CASE NO._____________________ ___________________________________________ ___________________________________________ Defendant SURRENDER OF UNBORN CHILD FOR PURPOSES OF ADOPTION 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 surrender and entrust the entire custody and control of such child to the_______________________ ___________________________________________________________________________________________________, (The Agency) a __________________________________________________ child welfare agency with its principal office in the City of (Public) (Licensed) ____________________________________, County of___________________________ and State of ________________, for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption and to consent to the legal adoption of such child, and that I have not previously executed a consent or surrender with respect to such child. That I hereby grant to said Agency full power and authority to place such child with any person or persons it may in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of such child by such person or persons; and to take any and all measures which, in the judgement of said Agency, may be for the best interests of such child, including authorizing medical, surgical and dental care and treatment, including inoculation and anaesthesia for such child. That I wish to and understand that by signing this consent I do irrevocably and permanently give up all custody and other parental rights I have to such child. That I understand I cannot under any circumstances, after signing this surrender, change my mind and revoke or cancel this surrender or obtain or recover custody or any other rights over such child, except that I have the right to revoke this surrender by giving written notice of my revocation not later than 72 hours after the birth of such child. That I have read and understand the above and I am signing it as my free and voluntary act. Dated_____________________________, 20_____ ________________________________________ (Witness) 2000 © American LegalNet, Inc. STATE OF ILLINOIS) ) SS COUNTY OF WILL ) I,_____________________________________, do hereby certify that_______________________________ (Name and Official Title) personally known to me to be the same person whose name is subscribed to the foregoing Surrender, appeared before me this day in person and acknowledged that he signed and delivered such Surrender 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____ _______________________________________________ (Notary Public) 2000 © American LegalNet, Inc.