Forms of consent and surrender; execution and acknowledgment thereof. A. The form of consent required for the adoption of a born child shall be substantially as follows:

FINAL AND IRREVOCABLE CONSENT TO ADOPTION I, ...., (relationship, e.g., mother, father, relative, guardian) of ...., a ..male child, state:

That such child was born on .... at ....

That I reside at ...., County of .... and State of ....

That I am of the age of .... years.

That I hereby enter my appearance in this proceeding and waive service of summons on me.

That I do hereby consent and agree to the adoption of 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 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 (insert date).

.........................

If under Section 8 the consent of more than one person is required, then each such person shall execute a separate consent.

B. The form of consent required for the adoption of an unborn child shall be substantially as follows:

CONSENT TO ADOPTION OF UNBORN CHILD I, ...., state:

That I am the father of a child expected to be born on or about .... to .... (name of mother).

That I reside at .... County of ...., and State of .....

That I am of the age of .... years.

That I hereby enter my appearance in such adoption proceeding 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, except as hereinabove provided, 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 (insert date).

........................

B-5. (1) The parent of a child may execute a consent to standby adoption by a specified person or persons. A consent under this subsection B-5 shall be acknowledged by a parent pursuant to subsection H and subsection K of this Section. The form of consent required for the standby adoption of a born child effective at a future date when the consenting parent of the child dies or requests that a final judgment of adoption be entered shall be substantially as follows:

FINAL AND IRREVOCABLE CONSENT TO STANDBY ADOPTION I, ..., (relationship, e.g. mother or father) of ...., a ..male child, state:

That the child was born on .... at .....

That I reside at ...., County of ...., and State of .....

That I am of the age of .... years.

That I hereby enter my appearance in this proceeding and waive service of summons on me in this action only.

That I do hereby consent and agree to the standby adoption of the child, and that I have not previously executed a consent or surrender with respect to the 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 the child, effective upon (my death) (the child's other parent's death) or upon (my) (the other parent's) request for the entry of a final judgment for adoption if ..... (specified person or persons) adopt my child.

That I understand that until (I die) (the child's other parent dies), I retain all legal rights and obligations concerning the child, but at that time, I irrevocably give all custody and other parental rights to .... (specified person or persons).

I understand my child will be adopted by ....... (specified person or persons) only 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 my child if ..... (specified person or persons) adopt my child.

I understand that this consent to standby adoption is valid only if the petition for standby adoption is filed and that if ....... (specified person or persons), for any reason, cannot or will not file a petition for standby adoption or if his, her, or their petition for standby adoption is denied, then this consent is void. I have the right to notice of any other proceeding that could affect my parental rights.

That I have read and understand the above and I am signing it as my free and voluntary act.

Dated (insert date).

....................

If under Section 8 the consent of more than one person is required, then each such person shall execute a separate consent. A separate consent shall be executed for each child.

(2) If the parent consents to a standby adoption by 2 specified persons, then the form shall contain 2 additional paragraphs in substantially the following form:

If .... (specified persons) obtain a judgment of dissolution of marriage before the judgment for adoption is entered, then ..... (specified person) shall adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody of my child if ..... (specified persons) obtain a judgment of dissolution of marriage and ..... (specified person) adopts my child. I understand that I cannot change my mind and revoke this consent if ...... (specified persons) obtain a judgment of dissolution of marriage before the adoption is final. I understand that this consent to adoption has no effect on who will get custody of my child if ..... (specified persons) obtain a judgment of dissolution of marriage after the adoption is final. I understand that if either ..... (specified persons) dies before the petition to adopt my child is granted, then the surviving person may adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody of my child if the surviving person adopts my child.

A consent to standby adoption by specified persons on this form shall have no effect on a court's determination of custody or visitation under the Illinois Marriage and Dissolution of Marriage Act if the marriage of the specified persons is dissolved before the adoption is final.

(3) The form of the certificate of acknowledgement for a Final and Irrevocable Consent for Standby Adoption shall be substantially as follows:

STATE OF .....)

) SS.

COUNTY OF ....)

I, ....... (name of Judge or other person) ..... (official title, name, and address), certify that ......., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent to Standby Adoption, appeared before me this day in person and acknowledged that (she) (he) signed and delivered the consent as (her) (his) free and voluntary act, for the specified purpose.

I have fully explained that this consent to adoption is valid only if the petition to adopt is filed, and that if the specified person or persons, for any reason, cannot or will not adopt the child or if the adoption petition is denied, then this consent will be void. I have fully explained that if the specified person or persons adopt the child, by signing this consent (she) (he) is irrevocably and permanently relinquishing all parental rights to the child, and (she) (he) has stated that such is (her) (his) intention and desire.

Dated (insert date).

Signature..............................

(4) If a consent to standby adoption is executed in this form, the consent shall be valid only if the specified person or persons adopt the child. The consent shall be void if:

(a) the specified person or persons do not file a petition for standby adoption of the child; or

(b) a court denies the standby adoption petition.

The parent shall not need to take further action to revoke the consent if the standby adoption by the specified person or persons does not occur, notwithstanding the provisions of Section 11 of this Act.

C. The form of surrender to any agency given by a parent of a born child who is to be subsequently placed for adoption shall be substantially as follows and shall contain such other facts and statements as the particular agency shall require.

FINAL AND IRREVOCABLE SURRENDER FOR PURPOSES OF ADOPTION I, .... (relationship, e.g., mother, father, relative, guardian) of ...., a ..male child, state:

That such child was born on ...., at .....

That I reside at ...., County of ...., and State of .....

That I am of the age of .... years.

That I do hereby surrender and entrust the entire custody and control of such child to the .... (the "Agency"), a (public) (licensed) child welfare agency with its principal office in the City of ...., 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.

That I hereby grant to the 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 judgment of the 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 surrender 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.

That I have read and understand the above and I am signing it as my free and voluntary act.

Dated (insert date).

........................

D. The form of surrender to an agency given by a parent of an unborn child who is to be subsequently placed for adoption shall be substantially as follows and shall contain such other facts and statements as the particular agency shall require.

SURRENDER OF UNBORN CHILD FOR PURPOSES OF ADOPTION I, .... (father), state:

That I am the father of a child expected to be born on or about .... to .... (name of mother).

That I reside at ...., County of ...., and State of .....

That I am of the age of .... years.

That I hereby grant to the 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 judgment of the 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 surrender 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 (insert date).

........................

E. The form of consent required from the parents for the adoption of an adult, when such adult elects to obtain such consent, shall be substantially as follows:

CONSENT I, ...., (father) (mother) of ...., an adult, state:

That I reside at ...., County of .... and State of .....

That I do hereby consent and agree to the adoption of such adult by .... and .....

Dated (insert date).

.........................

F. The form of consent required for the adoption of a child of the age of 14 years or upwards, or of an adult, to be given by such person, shall be substantially as follows:

CONSENT I, ...., state:

That I reside at ...., County of .... and State of ..... That I am of the age of .... years. That I consent and agree to my adoption by .... and .....

Dated (insert date).

........................

G. The form of consent given by an agency to the adoption by specified persons of a child previously surrendered to it shall set forth that the agency has the authority to execute such consent. The form of consent given by a guardian of the person of a child sought to be adopted, appointed by a court of competent jurisdiction, shall set forth the facts of such appointment and the authority of the guardian to execute such consent.

H. A consent (other than that given by an agency, or guardian of the person of the child sought to be adopted appointed by a court of competent jurisdiction) shall be acknowledged by a parent before the presiding judge of the court in which the petition for adoption has been, or is to be filed or before any other judge or hearing officer designated or subsequently approved by the court, or the circuit clerk if so authorized by the presiding judge or, except as otherwise provided in this Act, before a representative of the Department of Children and Family Services or a licensed child welfare agency, or before social service personnel under the jurisdiction of a court of competent jurisdiction, or before social service personnel of the Cook County Department of Supportive Services designated by the presiding judge.

I. A surrender, or any other document equivalent to a surrender, by which a child is surrendered to an agency shall be acknowledged by the person signing such surrender, or other document, before a judge or hearing officer or the clerk of any court of record, either in this State or any other state of the United States, or before a representative of an agency or before any other person designated or approved by the presiding judge of the court in which the petition for adoption has been, or is to be, filed.

J. The form of the certificate of acknowledgment for a consent, a surrender, or any other document equivalent to a surrender, shall be substantially as follows:

STATE OF ....)

) SS.

COUNTY OF ...)

I, .... (Name of judge or other person), .... (official title, name and location of court or status or position of other person), certify that ...., personally known to me to be the same person whose name is subscribed to the foregoing (consent) (surrender), appeared before me this day in person and acknowledged that (she) (he) signed and delivered such (consent) (surrender) as (her) (his) free and voluntary act, for the specified purpose.

I have fully explained that by signing such (consent) (surrender) (she) (he) is irrevocably relinquishing all parental rights to such child or adult and (she) (he) has stated that such is (her) (his) intention and desire.

Dated (insert date).

Signature ...............

K. When the execution of a consent or a surrender is acknowledged before someone other than a judge or the clerk of a court of record, such other person shall have his signature on the certificate acknowledged before a notary public, in form substantially as follows:

STATE OF ....)

) SS.

COUNTY OF ...)

I, a Notary Public, in and for the County of ......, in the State of ......, 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 (she) (he) signed such certificate as (her) (his) free and voluntary act and that the statements made in the certificate are true.

Dated (insert date). Signature ...................... Notary Public (official seal)

There shall be attached a certificate of magistracy, or other comparable proof of office of the notary public satisfactory to the court, to a consent signed and acknowledged in another state.

L. A surrender or consent executed and acknowledged outside of this State, either in accordance with the law of this State or in accordance with the law of the place where executed, is valid.

M. Where a consent or a surrender is signed in a foreign country, the execution of such consent shall be acknowledged or affirmed in a manner conformable to the law and procedure of such country.

N. If the person signing a consent or surrender is in the military service of the United States, the execution of such consent or surrender may be acknowledged before a commissioned officer and the signature of such officer on such certificate shall be verified or acknowledged before a notary public or by such other procedure as is then in effect for such division or branch of the armed forces.

O. (1) The parent or parents of a child in whose interests a petition under Section 2-13 of the Juvenile Court Act of 1987 is pending may, with the approval of the designated representative of the Department of Children and Family Services, execute a consent to adoption by a specified person or persons:

(a) in whose physical custody the child has resided for at least 6 months; or (b) in whose physical custody at least one sibling of the child who is the subject of this consent has resided for at least 6 months, and the child who is the subject of this consent is currently residing in this foster home; or (c) in whose physical custody a child under one year of age has resided for at least 3 months. A consent under this subsection O shall be acknowledged by a parent pursuant to subsection H and subsection K of this Section.

(2) The consent to adoption by a specified person or persons shall have the caption of the proceeding in which it is to be filed and shall be substantially as follows:

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR PERSONS I, ......................................, the .................. (mother or father) of a ....male child, state:

1. My child ............................ (name of child) was born on (insert date) at .................... Hospital in ................ County, State of ............... 2. I reside at ......................, County of ............. and State of .............. 3. I, ..........................., am .... years old.

4. I enter my appearance in this action to adopt my child by the person or persons specified herein by me and waive service of summons on me in this action only. 5. I consent to the adoption of my child by ............................. (specified person or persons) only. 6. I wish to sign this consent and I understand that by signing this consent I irrevocably and permanently give up all parental rights I have to my child if my child is adopted by ............................. (specified person or persons). 7. I understand my child will be adopted by ............................. (specified person or persons) only 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 my child if ............................ (specified person or persons) adopt my child. 8. I understand that this consent to adoption is valid only if the petition to adopt is filed within one year from the date that I sign it and that if ....................... (specified person or persons), for any reason, cannot or will not file a petition to adopt my child within that one year period or if their adoption petition is denied, then this consent will be voidable after one year upon the timely filing of my motion. If I file this motion before the filing of the petition for adoption, I understand that the court shall revoke this specific consent. I have the right to notice of any other proceeding that could affect my parental rights, except for the proceeding for ............. (specified person or persons) to adopt my child. 9. I have read and understand the above and I am signing it as my free and voluntary act. Dated (insert date).

.............................................

Signature of parent

(3) If the parent consents to an adoption by 2 specified persons, then the form shall contain 2 additional paragraphs in substantially the following form:

10. If ............... (specified persons) get a divorce before the petition to adopt my child is granted, then .......... (specified person) shall adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody over my child if ............. (specified persons) divorce and ............. (specified person) adopts my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody over my child if ................. (specified persons) divorce after the adoption is final. I understand that this consent to adoption has no effect on who will get custody of my child if they divorce after the adoption is final. 11. I understand that if either ............... (specified persons) dies before the petition to adopt my child is granted, then the surviving person can adopt my child. I understand that I cannot change my mind and revoke this consent or obtain or recover custody over my child if the surviving person adopts my child. A consent to adoption by specified persons on this form shall have no effect on a court's determination of custody or visitation under the Illinois Marriage and Dissolution of Marriage Act if the marriage of the specified persons is dissolved after the adoption is final.

(4) The form of the certificate of acknowledgement for a Final and Irrevocable Consent for Adoption by a Specified Person or Persons shall be substantially as follows:

STATE OF..............)

) SS.

COUNTY OF.............)

I, .................... (Name of Judge or other person), ..................... (official title, name, and address), certify that ............., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent for Adoption by a Specified Person or Persons, appeared before me this day in person and acknowledged that (she)(he) signed and delivered the consent as (her)(his) free and voluntary act, for the specified purpose.

I have fully explained that this consent to adoption is valid only if the petition to adopt is filed within one year from the date that it is signed, and that if the specified person or persons, for any reason, cannot or will not adopt the child or if the adoption petition is denied, then this consent will be voidable after one year upon the timely filing of a motion by the parent to revoke the consent. I explained that if this motion is filed before the filing of the petition for adoption, the court shall revoke this specific consent. I have fully explained that if the specified person or persons adopt the child, by signing this consent this parent is irrevocably and permanently relinquishing all parental rights to the child, and this parent has stated that such is (her)(his) intention and desire.

Dated (insert date).

...............................

Signature

(5) If a consent to adoption by a specified person or persons is executed in this form, the following provisions shall apply. The consent shall be valid only if that specified person or persons adopt the child. The consent shall be voidable after one year if:

(a) the specified person or persons do not file a petition to adopt the child within one year after the consent is signed and the parent files a timely motion to revoke this consent. If this motion is filed before the filing of the petition for adoption the court shall revoke this consent; or (b) a court denies the adoption petition; or

(c) the Department of Children and Family Services Guardianship Administrator determines that the specified person or persons will not or cannot complete the adoption, or in the best interests of the child should not adopt the child. Within 30 days of the consent becoming void, the Department of Children and Family Services Guardianship Administrator shall make good faith attempts to notify the parent in writing and shall give written notice to the court and all additional parties in writing that the adoption has not occurred or will not occur and that the consent is void. If the adoption by a specified person or persons does not occur, no proceeding for termination of parental rights shall be brought unless the biological parent who executed the consent to adoption by a specified person or persons has been notified of the proceeding pursuant to Section 7 of this Act or subsection (4) of Section 2-13 of the Juvenile Court Act of 1987. The parent shall not need to take further action to revoke the consent if the specified adoption does not occur, notwithstanding the provisions of Section 11 of this Act.

(6) The Department of Children and Family Services is authorized to promulgate rules necessary to implement this subsection O.

(7) The Department shall collect and maintain data concerning the efficacy of specific consents. This data shall include the number of specific consents executed and their outcomes, including but not limited to the number of children adopted pursuant to the consents, the number of children for whom adoptions are not completed, and the reason or reasons why the adoptions are not completed.

(Source: P.A. 92-320, eff. 1-1-02; 93-732, eff. 1-1-05.)

Last modified: April 6, 2006