Agency Consent To Adoption Of Minor Child {K.S.A. 59-2129}

Rev. 07/2018 KSJC 1 [CAPTION] AGENCY CONSENT TO ADOPTION OF MINOR CHILD (Name of agency) , a (public)(private) entity having for its purpose the care and maintenance of children, is located in and authorized under the laws of the State of to place children for adoption, consent to the adoption and to stand in loco parentis to such children until they are adopted or reach majority. (Name of agency) , is vested with the right to consent to the adoption of (name of child) , a minor child born (date of birth) at (place of birth) pursuant to [a relinquishment executed by (the parents of the child)(the person in loco parentis to the child)] [an order or judgment of the Court of County, , a Court of competent jurisdiction]. Documents supporting the authority to execute this consent are attached to this consent. (Name of agency) consents to the adoption of (name of child) by resident(s) of and surrenders the child to (him)(her)(them) for the purpose of adoption. (Name of agency) has authorized (name of authorized representative) the undersigned, as the authorized representative to execute consents to adoption on behalf of the agency. [ (Name of agency) waives notice of the final hearing of the adoption.] Date (Signature of authorized representative) ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER STATE OF ) ) COUNTY OF ) This consent was acknowledged before me on (date) at (time) by (name of person). (signature of notarial officer) (SEAL, if any) title (and rank) [My Appointment Expires: ] Authority: K.S.A. 59-2143 American LegalNet, Inc. www.FormsWorkFlow.com