in the circuit court for the twenty-third judicial...
TRANSCRIPT
IN THE CIRCUIT COURT FOR THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_________________________________ ) CASE NO. _______________________________
_________________________________ )
Petitioner(s), )
)
vs. )
__________________________________ )
__________________________________ )
Respondent(s).
ACKNOWLEDGEMENT OF INFORMATION ON THE ILLINOIS ADOPTION
REGISTRY AND MEDICAL INFORMATION EXCHANGE
I, _________________________________ have signed the Final and Irrevocable Consent to Adoption (relationship, e.g., mother, father, guardian)
for a child born on _____________________________ at ____________________________________.
I have been given the Illinois Department of Public Health “Illinois has put the option back in adoption”
which provides information on the Illinois Adoption Registry and Medical Information Exchange.
_______________________________________________________
Name
___________________________________________, 20_________
Date
Acknowledgement of IL Adoption Registry & Medical Info
04-01-16 lks
Petition for Adoption/p.1
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
____________________________________________
____________________________________________
Petitioner(s),
vs.
____________________________________________
____________________________________________
Respondent(s).
)
)
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)
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)
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)
CASE NO.________________________________
PETITION FOR ADOPTION
NOW COME(S) Petitioner(s) herein and allege as follows:
(a) The full name(s) of the Petitioner(s) and, if minor(s), his/her respective age(s) is/are as follows:
Name_________________________________________________________________________________ Age__________
Name_________________________________________________________________________________ Age__________
(b) The place of residence of Petitioner(s) and the length of residence in Illinois (of each) immediately preceding
the filing of the within Petition is/are as follows:
Place_______________________________________________________________________________ Length__________
Place_______________________________________________________________________________ Length__________
(c) The Petitioners(s) acquired/intend(s) to acquire custody of said child from _____________________________
____________________________________whose address is__________________________________________________
______________________________________________________on_________________________, 20_____.
(d) The name, place, date of birth and sex of the child sought to be adopted is as follows:____________________
____________________________________________________________________________________________________
.
(e) The relationship, if any, of the child to each Petitioner is as follows:__________________________________
____________________________________________________________________________________________________
(f) The names of the parents of the child, place of residence and whether minor or adult are as follows:
Father ___________________________________ Age__________
Residence_____________________________________
Mother ___________________________________ Age__________
Residence_____________________________________
Neither of the parents are under any legal disability except:______________________________________________
____________________________________________________________________________________________________
(1) The rights of the parents have been terminated by _____________________________________________,
a court of competent jurisdiction.
(2) The child has been surrendered to the following agency: ________________________________________
____________________________________________________________________________________________________
Petition for Adoption/p.2
Rev. 04-01-16
(3) The parent(s), namely____________________________________________________________________
has/have been served with the notice provided in Section 12a of this Act and ________________________
__________________________________ has filed ___________________________________________
(g) The child has no living parent(s). The legal guardian of the child is __________________________________
who was appointed by _________________________________________________________________________________
(h) The child has no living parent(s) and no legal guardian is known. The name of a near relative is
_________________________ Relationship____________________ Address_____________________________________
____________________________________________________________________________________________________
(i) The name to be given the child (adult) is _______________________________________________________
(j) (1) That ______________________________________________, being the person/agency having authority
to do so, has/have consented/indicated a willingness to consent to the adoption of the child by the Petitioner(s).
(2) That ______________________________________________, has authority to consent to the adoption
of the child by Petitioner(s), is an/are unfit person(s) for the following reason(s):
____________________________________________________________________________________________________
(k) Orders, judgments or decrees have been entered affecting:
(1) The adoption or custody of the child as follows:______________________________________________
____________________________________________________________________________________________________
(2) The adoptive, custodial or parental rights of either Petitioner as follows, including the prior denial of any
petition for adoption pertaining to such child, or to the Petitioner(s) or either of
them:_______________________________________________________________________________________________
____________________________________________________________________________________________________
(3) Additional allegation(s) required by the facts of this particular
case:________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
WHEREFORE, Petitioner(s) pray(s) that the above-named _____________________________________________
may be made Respondent(s) to this Petition, and that a Summons may issue for them and each of them, returnable according
to law, and that they and each of them be required to answer this petition as is by statute provided.
Petitioner(s) further pray(s) that the court will, on the final hearing of this Petition, ORDER, ADJUDGE and
DECREE that the said ______________________________ shall, to all legal intents and purposes, be the child of your
Petitioner(s), and that the name of said child shall thereafter be _________________________________________________
____________________________________________________________________________________________________
That this Honorable Court will make such other and further orders in the premises as may be in accordance with the
law.
__________________________________________ _____________________________________________
Signature of Petitioner Signature of Petitioner
__________________________________________ _____________________________________________
Petitioner (type or print name) Petitioner (type or print name)
Petition for Adoption/p.3
Rev. 04-01-16
STATE OF ILLINOIS )
) SS.
County of _________________ )
_______________________________________________, being first duly sworn upon oath depose(s) and say(s) that he/she
has read and signed the foregoing Petition and that the contents thereof are true and correct.
Name:________________________________________
Attorney for:___________________________________
Address:______________________________________
City/State/Zip:
_____________________________________________
Telephone:_____________________________________
____________________________________________
Signature of Petitioner
____________________________________________
Signature of Petitioner
Signed and sworn to before me this __________ day of
__________________________, 20______________.
____________________________________________
Notary Public
Summons - Adoption
Rev. 04-01-16/p.1
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
__________________________________________________
__________________________________________________
Plaintiff(s)/Petitioner(s),
vs.
__________________________________________________
__________________________________________________
Defendant(s)/Respondent(s).
)
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CASE NO. ____________________________
SUMMONS - ADOPTION
TO EACH DEFENDANT:
YOU ARE SUMMONED and required to file an answer in this case, or otherwise file your appearance in the Office of the
Circuit Clerk of this Court, located at 133 West State Street, Room 203, Sycamore, Illinois, within thirty (30) days after service of this
Summons, not counting the day of service. IF YOU FAIL TO DO SO, A JUDGMENT OR DECREE BY DEFAULT MAY BE TAKEN
AGAINST YOU FOR THE RELIEF ASKED IN THE COMPLAINT.
To the Officer:
This Summons must be returned by the Officer or other person to whom it was given for service, with endorsement of service and
fees, if any, immediately after service. If service cannot be made, this Summons shall be returned so endorsed.
This Summons may not be served later than thirty (30) days after its date.
(Seal of Court) WITNESS,___________________________, 20________
________________________________________________
Clerk of the Circuit Court
(Petitioner(s) Attorney or Petitioner if he/she is not represented by an attorney)
Name: __________________________________________
Attorney for: __________________________________________
Attorney Number: __________________________________________
Address: __________________________________________
City/State/Zip: __________________________________________
Telephone No.: __________________________________________
Date of Service ________________________, 20___
(To be inserted by Officer or Process Server on the copy left with the Respondent or other person)
Summons - Adoption
Rev. 04-01-16/p.2
SHERIFF'S FEES: Service and return $__________ + _______ Miles at $__________ per mile = total $__________.
Sheriff of _______________________________County
By:_______________________________________, Deputy
I certify that I served this Summons on defendant(s) as follows:
(a) - (Individual defendant(s)-personal):
(The officer or other person making service, shall (a) identify as to sex, race and approximate age of the defendant with whom she/he left
the Summons, and (b) state the place where (whenever possible in terms of an exact street address) and the date and time of day when the
Summons was left with the Defendant.)
DEFENDANT NAME ADDRESS WHERE SERVED DATE OF SERVICE SEX/RACE/APPROXIMATE AGE
(b) - (Individual defendant(s)-abode):
By leaving a copy of the Summons and Complaint at the usual place of abode of each individual defendant with a person of his family, of
the age of 13 years or upwards, informing that person of the contents of the Summons, and also by sending a copy of the Summons. (The
officer or other person making service, shall (a) identify as to sex, race and approximate age of the person, other than the Defendant, with
whom she/he left the Summons, and (b) state the place where (whenever possible in terms of an exact street address) and the date and time
of day when the Summons was left with the person.)
NAME OF PERSON SERVED ADDRESS WHERE SERVED DATE OF SERVICE SEX/RACE/APPROXIMATE AGE
Also, by sending a copy of the Summons and Complaint in a sealed envelope with postage fully prepaid, addressed to each individual
Defendant at his usual place of abode, as follows:
DEFENDANT NAME MAILING ADDRESS DATE OF MAILING
(c) - Corporation defendant(s):
By leaving a copy of the Summons and Complaint with the registered agent, officer or agent of each Defendant corporation, as follows:
DEFENDANT CORPORATION REGISTERED AGENT, OFFICER OR AGENT DATE OF SERVICE
(d) - (Other service):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Sheriff of _____________________________County
By:_________________________________, Deputy
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
NEW CASE INFORMATION SHEET
County of Kendall ) SS. CASE NO.________________________
County of DeKalb )
1. Case Type:____________ 2. Sub Case Type:________ 3. Claim Amount: $___________ 4. Jury: _________ (see reverse for codes) (see reverse for codes) (yes/no)
5. Domestic Relations cases only contested: _____________________ Date of Birth:______________________ (yes or no - if applicable) (juvenile case)
6. Event Date/Time:________________________________________ 7. Is real estate involved?_______________ (month) (date) (year) (yes/no)
8. First named plaintiff:_________________________________________________________________________
Address:__________________________________________ Address #2:______________________________
City:__________________________ State/Zip Code:__________________ Phone #:___________________
9. Plaintiff Attorney:____________________________________________________________________________ (State of Illinois Registration Number)
Name:_____________________________________________________________________________________ (Last) (First) (MI)
10. First named defendant:______________________________________________________________________
Address:________________________________________ Address #2:______________________________
City:________________________ State/Zip Code:__________________ Phone #:___________________
11. Second named plaintiff:______________________________________________________________________
Address:________________________________________ Address #2:______________________________
City:_______________________ State/Zip Code:__________________ Phone #:___________________
12. Second named defendant:_________________________________________ ___________________________
Address:________________________________________ Address #2:______________________________
City:_______________________ State/Zip Code:__________________ Phone #:___________________
13. List additional Plaintiffs by name, address, city, zip code &
phone # below (including AKAs & DBAs).
(Domestic Relations): List children under 18 by
name and DOB. Attach additional sheet if needed.
New Case Information Sheet
REV. 04-01-16
14. List additional Defendants by name, address, city, zip
code & phone # below (including A.K.A.’s &
D.B.A’s). Attach additional sheet if needed.
CIVIL CASE & SUB-CASE TYPE CODES
Law (L) ($50,001 and over)
0101 TORT $ DAMG AUTO - PROP
0102 TORT $ DAMG AUTO - PROP/PER INJ
0103 TORT $ DAMG AUTO - PER INJ
0104 TORT $ DAMG AUTO - PER INJ/DEATH
0105 TORT $ DAMG AUTO - DEATH
0106 TORT $ DAMG - OTHER
0107 CONTRACT - MONEY DAMAGES
0108 CONFESSION OF JUDGMENT
0109 FORCE ENTRY/DETAINER - POSS/$
0110 FORCE ENTRY/DETAINER - POSS ONLY
0111 DISTRESS FOR RENT
0112 STAT ACT / STATE / RECR SUPPT
0113 ARBITRATION & AWARD
0114 DETINUE
0115 EJECTMENT
0116 REPLEVIN
0117 TROVER
0118 MALPRACTICE - MEDICAL
0119 MALPRACTICE - LEGAL
0120 MALPRACTICE - OTHER
0121 ALIENATION OF AFFECTION
0122 CLASS ACTION SUIT
0123 REGISTRATION OF FOREIGN JUDG
0130 OTHER (SPECIFY)
Law Medium (LM) ($10,001 to $50,000)
0201 TORT - $ DAMG - AUTO - PROP
0202 TORT - $ DAMG - AUTO - PROP/PER INJ
0203 TORT - $ DAMG - AUTO - PER INJ
0204 TORT - $ DAMG - AUTO - PER INJ/DEATH
0205 TORT - $ DAMG - AUTO - DEATH
0206 TORT - $ DAMG - OTHER
0207 CONTRACT MONEY DAMAGES
0208 CONFESSION OF JUDGMENT
0210 FORCIBLE ENTRY / DETAINER POSS/$
0211 DISTRESS FOR RENT
0212 STAT ACT / STATE / RECR SUPPT
0213 ARBITRATION & AWARD
0214 DETINUE
0215 EJECTMENT
0216 REPLEVIN
0217 TROVER
0218 MALPRACTICE - MEDICAL
0219 MALPRACTICE - LEGAL
0220 MALPRACTICE - OTHER
0221 ALIENATION OF AFFECTION
0222 CLASS ACTION SUIT
0223 REGISTRATION OF FOREIGN JUDG
0230 OTHER (SPECIFY)
Small Claims (SC) (up to $10,000)
0301 CONTRACT - MONEY - DAMAGES
0302 TORT - $ DAMG - AUTO
0303 TORT - $ DAMG - OTHER
0304 TAX COLLECTION
0305 REGISTRATION OF FOREIGN JUDG
0330 OTHER (SPECIFY)
Eminent Domain (ED)
0501 CONDEMNATION
0530 OTHER (SPECIFY)
Mental Health (MH)
1101 PETN FOR HOSPITALIZATION
1102 PETN FOR DISCHARGE
1103 PETN FOR RESTORATION
1104 AUTH EMGCY MED/DENTAL TRETMNT
1105 AUTH PSYCHOTROPIC MEDICATION
1106 ADMINISTRATOR TO ADMIN TRETMNT
1130 OTHER (SPECIFY)
Miscellaneous Remedies (MR)
0601 JUDICIAL REVIEW / ADMIN
0602 JUDICIAL REVIEW / WORKERS COMP
0603 JUDICIAL REVIEW / UNEMPLOYMENT
0604 DECLARATORY JUDGMENT
0605 CORPORATION DISSOLUTION
0606 CHANGE OF NAME
0607 HABEAS CORPUS
0608 MANDAMUS
0609 PROHIBITION
0610 QUO WARRANTO
0611 ATTACH/ORIGINAL ACTION
0612 NE EXEAT / ORIGINAL ACTION
0613 ESCHEAT
0614 LOST GOODS OR MONEY
0615 BURNT RECORDS
0616 ELECTION CONTEST
0617 DISCOVERY
0618 SEARCH WARRANT
0619 FORFEITURE OF SEIZED PROPERTY
0620 CONTEMPT OF COURT
0621 REG OF FICTITIOUS RECORD
0622 SEX TRANSMISS DISEASE CONTROL
0623 CONTAGIOUS/ INFECTIOUS DISEASE
0624 REGISTRATION OF FOREIGN JUDG
0625 PETN ISSUE FOREIGN SUBPOENA
0626 EASVESDROPPING/CRIMINAL SURVEY
0627 DEMOLITION
0628 EXTRADITION
0630 OTHER (SPECIFY)
0631 SEXUALLY VIOLENT PERSONS ACT
0635 ANNEXATION
Chancery (CH)
0701 INJUNCTION (EXCEPT TX OR D CASES)
0702 RESIDENTIAL REAL ESTATE MORTG
FORECLOSURE
0703 MECHANIC LIEN FORECLOSE
0704 FORECLOSURE SEC / INTEREST /
PERS-PROP
0705 PARTNERSHIP DISSOLUTION
0706 SPECIFIC PERFORMANCE
0707 PARTITION
0710 CONST / INTER VIVOS TRUST
0711 CONST / TESTAMENTARY TRUST
0712 TRUST ADMINISTRATION
0713 QUIET TITLE
0714 COMPLAINT IN EQUITY
0715 ACCOUNTING
0716 RECEIVERSHIP
0717 RECESSION OF CONTRACT
0718 CREDITOR’S COMPLAINT
0719 UNIFORM GIFT TO MINOR ACT
0720 SETTING ASIDE A DEED
0721 FORECLOSURE ON CONDO ASSMT
0722 INTERPLEADER
0723 REGISTRATION OF FOREIGN JUDG
0724 STRUCTURED SETLMNT (ORIG ACT
TO ASSIGN)
0730 OTHER (SPECIFY)
0731 BUSINESS REAL ESTATE MORTG
FORECLOSURE
Tax (TX)
0401 REC OF DELIN PERS PROP TAXES
0402 RETAILERS OCCUPATION TAX
0403 PETITION FOR TAX REFUND
0404 TAX FORECLOSURE
0405 TAX INJUNCTION
0406 ANNUAL TAX SALE
0407 SCAVENGER TAX SALE
0408 TAX OBJECTION
0409 TAX COMMISSION (REV DEC)
0410 DRAINAGE ASSESSMENT
0411 SPECIAL ASSESSMENT
0412 FORECLOSE LIEN/ SPEC ASSMT
0413 SUIT / RESTRAIN COLL / SPEC ASSMT
0414 TAX DEED
0415 PETITION FOR RECOVERY
0416 REGISTRATION OF FOREIGN JUDG
0417 SALE IN ERROR
0430 OTHER (SPECIFY)
Municipal Corporation (MC)
1301 PETN /ORGANIZE MUN CORP
1302 PETN /DISSOLVE MUN CORP
1303 PETN /CREATION OF DRAINAGE
1304 PETN /CHANGE OF GOVERNMENT
1330 OTHER (SPECIFY)
Adoption (AD)
0801 ADOPTION
0817 ADOPTION UNBORN CHILD
Divorce (D)
0901 DISSOLUTION
0902 INVALIDITY
0903 LEGAL SEPARATION
0906 SIMPLIFIED DISSOLUTION
0907 REGISTRATION OF FOREIGN JUDG
0908 DISSOLUTION – CIVIL UNION
0930 OTHER (SPECIFY)
Family (F)
0802 PUTATIVE FATHER
0803 PATERNITY
0804 PARENT & CHILD RELATIONSHIP
0806 RECIPROCAL NON-SUPPORT
0807 NEGLECT & REFUSAL TO SUPPT
0808 CIVIL ACTION TO COMPEL SUPPORT
0809 URESA - INCOMING
0810 URESA - OUTGOING
0811 REGISTRATION OF FOREIGN JUDG
0812 MEDICAL ASST NO GRANT (MANG)
0813 PATERNITY (MANG)
0814 NEGLECT & REFUSAL TO SUPPT (MANG)
0815 URESA - INCOMING (MANG)
0816 URESA - OUTGOING (MANG)
0818 CONFIDENTIAL INTERMEDIARY
0830 OTHER (SPECIFY)
0904 PETITION FOR CUSTODY
0905 PETITION FOR VISITATION
1005 EMANCIPATION
1006 ORDER FOR MARRIAGE LICENSE
Order of Protection (OP)
0805 ORDER OF PROTECTION
0819 REGISTRATION OF FOREIGN JUDG
0822 CIVIL NO CONTACT ORDERS
0823 STALKING NO CONTACT ORDERS
Juvenile (J)
1002 SUPERVISION
1003 DEPENDENCY
1007 ADDICTED MINOR
1008 TRUANCY
1009 MINOR REQ AUTH INTERVENTION
1010 TEMPORARY GUARDIAN
1030 OTHER (SPECIFY)
Juvenile Neglect and Abuse (JA)
1004 NEGLECT AND ABUSE
Juvenile Delinquency (JD)
1001 DELINQUENCY
Final & Irrevocable Consent to Adoption
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
)
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CASE NO. ______________________________
FINAL AND IRREVOCABLE CONSENT TO ADOPTION
I, ______________________________________________ of _________________________________________________ (relationship, e.g. mother, father, guardian)
a female/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 hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and Responsibilities – Private
Form before signing this consent and that I have had time to read, or have had read to me, this form. I understand that if I do not
receive any of the rights as described in this form, it shall not constitute a basis to revoke this Final and Irrevocable Consent.
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 this__________ day of ________________, 20_____. _______________________________________________
STATE OF ILLINOIS )
) SS.
County of _________________ )
I,_________________________________________, do hereby certify 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/she signed and delivered such consent as her/his free and voluntary act, for the specified purpose.
I have fully explained that by signing such consent he/she is irrevocably relinquishing all parental rights to such child or adult
and he/she has stated that such is his/her intention and desire.
In Witness Whereof, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.
________________________________________________
Consent by Adult to Adoption
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
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CASE NO. ______________________________
CONSENT BY ADULT OR CHILD
OF THE AGE OF FOURTEEN YEARS OR OVER TO ADOPTION
I, ______________________________________________________________, state:
That I reside at __________________________________________________________, County of_____________________________
and State of _______________________________________.
That I hereby enter my appearance in this proceeding and waive service of summons on me.
That I am of the age of ____________ years.
That I consent and agree to my adoption by ________________________________________________________________________ and
_________________________________________________.
Dated this__________ day of __________________________, 20_______. _______________________________________________
STATE OF ILLINOIS )
) SS.
COUNTY OF ___________________ )
I, ________________________________________________________________________________________, do hereby certify that
(Name and Official Capacity)
________________________________________ 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/she signed and delivered such consent as her/his voluntary act, for the specified
purpose.
I have fully explained that by signing such consent he/she is irrevocably electing to become, to all legal intents and purposes, the child of
the Petitioner _____ named in said Petition, and he/she has stated that such is his/her intention or desire.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.
_______________________________________________
_______________________________________________
STATE OF ILLINOIS )
) SS.
COUNTY OF ___________________ )
I, ____________________________________________________, a Notary Public in and for said County, in the State aforesaid, do
hereby certify that the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me this day in person
and acknowledged that he/she signed such certificate as his/her voluntary act and that the statements made in said certificate are true.
Given under my hand and notarial seal this ___________ day of _____________________, 20_______.
(Official Seal) _______________________________________________
Notary Public
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
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CASE NO. ______________________________
CONSENT TO ADOPTION OF ADULT
I, ______________________________________________________________, father/mother of _______________________________,
an adult, state:
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 adult by _______________________________________________________
and _________________________________________________.
Dated this__________ day of __________________________, 20_____. _______________________________________________
STATE OF ILLINOIS )
) SS.
COUNTY OF ___________________ )
I,__ ________________________________________________________________________________________, do hereby certify that
(Name and Official Capacity)
________________________________________ 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/she signed and delivered such consent as his/her free and voluntary act, for the
specified purpose.
I have fully explained that by signing such consent he/she is irrevocably relinquishing all parental rights to such adult and he/she has stated
that such is his/her intention or desire.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.
_______________________________________________
_______________________________________________
STATE OF ILLINOIS )
) SS.
COUNTY OF ___________________ )
I, ____________________________________________________, a Notary Public in and for said County, in the State aforesaid, do
hereby certify that the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me this day in person
and acknowledged that he/she signed such certificate as his/her voluntary act and that the statements made in said certificate are true.
Given under my hand and notarial seal this ___________ day of _____________________, 20_______.
(Official Seal)
_______________________________________________
Notary Public Consent to Adoption of Adult
Rev. 04-01-2016
Final & Irrevocable Surrender-Adoption
Rev. 04-01-16/p.1
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS _______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
)
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CASE NO._______________________________
FINAL AND IRREVOCABLE SURRENDER FOR PURPOSES OF ADOPTION I, _________________________________________of ____________________________________________,
(relationship)
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
_________________________________________________________________________________________________ (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 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 judgment of said Agency, may be for the best
interests of such child, including authorizing medical, surgical and dental care and treatment including inoculation and
anesthesia 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.
______________________________________ ____________________________________________
Signature Witness
Dated this ________ day of _________________________, 20_____.
Final & Irrevocable Surrender-Adoption
Rev. 04-01-16/p.2
STATE OF ILLINOIS
SS.
COUNTY OF DEKALB
I,
_________________________________________________________________________________________,
(name and official title)
do hereby certify that ______________________________________, 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 (she) (he) signed and delivered such Surrender as (her) (his) free and voluntary act, for the
specified purpose.
I have fully explained that by signing such consent (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.
In Witness Whereof, I have hereunto affixed my signature this ______ day of ____________________,
20 _____.
STATE OF ILLINOIS
SS.
COUNTY OF DEKALB
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 acknowledgement, 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 said
certificate are true.
Given under my hand and notarial seal this ______ day of _____________________________, 20____.
(OFFICIAL SEAL) ____________________________________________
Notary Public
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.1
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
IN THE MATTER OF THE ADOPTION OF: ) CASE NO. ____________________________
)
)
)
____________________________________ )
A Minor
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
A SPECIFIED PERSON OR PERSONS: DCFS CASE
I, __________________________________, the mother/father of ________________________
a male/female child, state that:
1. My child, ____________________________________, was born on ________________
at _____________________________ Hospital in the municipality of _______________
in ___________________________ County, State of ____________________________.
2. I reside at ______________________________________________________, County of
________________________, State of _________________________ Zip Code ______.
Mail may also be sent to me at this address: _______________________________________
In care of: __________________________________________________________________
My home telephone number is: _________________________________________________
My cell telephone number is: ___________________________________________________
My e-mail address is: _________________________________________________________
3. I, _______________________________________, am ________________ years of age.
4. I enter my appearance in this action for my child to be adopted by the person or persons
specified herein by me and waive service of summons on me in this action only.
5. I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and
Responsibilities in Illinois for Final and Irrevocable Consents to Adoption by a Specified
Person or Persons for DCFS Cases before signing this Consent and that I have had time
to read this form, or have it read to me, and that I understand the rights and
responsibilities described in this form. I understand that if I do not receive any of my
rights as described in this form, it shall not constitute a basis to revoke this Final and
Irrevocable Consent to Adoption by a Specified Person or Persons.
6. I do hereby consent to the adoption of such child by _____________________________
________________________________________ only.
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.2
7. I wish to sign this Consent and I understand that by signing this Consent, I irrevocably
and permanently give up all my parental rights I have to my child.
8. I understand that this Consent allows my child to be adopted by ____________________
________________________ only and that I cannot under any circumstances, after
signing this document, change my mind and revoke or cancel this Consent.
If the parent consents to an adoption by two specified persons, complete the following:
8a. I understand that if ____________________________________________________ and
___________________________________ get a divorce or are granted a dissolution of a
civil union before the petition to adopt my child is granted, this Consent remains valid for
_________________________________________________ (identify specified person)
to adopt my child. I understand that I cannot change my mind and revoke this consent or
obtain or revoke custody over my child if __________________________________ and
_______________________________________ divorce or are granted a dissolution of a
civil union.
8b. I understand that if either _________________________________________________ or
____________________________________ dies before the petition to adopt my child is
granted, this Consent remains valid for the surviving person to adopt my child. I
understand that I cannot change my mind and revoke this Consent or obtain or recover
custody over my child on the basis that one of the specified persons dies.
9. I understand that this Consent will be void if:
a. the Department places my child with someone other than the specified person or
persons; or
b. a court denies the adoption petition for the person or persons to adopt my child; or
c. the DCFS Guardianship Administrator refuses to consent to my child’s adoption by
the specified person or persons on the basis that the adoption is not in my child’s best
interest.
I understand that if this consent is void, I have parental rights to my child, subject to any
applicable court orders including those entered under Article II of the Juvenile Court Act
of 1987, unless and until I sign a new consent or surrender or my parental rights are
involuntarily terminated. I understand that if this Consent is void, my child may be
adopted by someone other than the specified person or persons only if I sign a new
consent or surrender, or my parental rights are involuntarily terminated. I understand that
if this Consent is void, the Department will notify me within 30 days using the addresses
and telephone numbers I provided in paragraph 2 of this form. I understand that if I
receive such notice, it is very important that I contact the Department immediately and
preferably within 30 days, to have input into the plan for my child’s future.
10. I understand that if a petition for adoption of my child is filed by someone other than ___
_________________________________________, the Department will notify me within
14 days after the Department becomes aware of the petition. If someone other than ____
_________________________________________ (specified person(s)) files a petition to
adopt my child, this consent remains valid only for ______________________________
(specified person(s)) to adopt by child.
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.3
11. If a person(s) other than the specified person or persons files a petition to adopt my child
or if the consent is void under paragraph 9, the Department will send written notice to me
using the mailing address and email address provided by me in paragraph 2 of this form.
The Department will also contact me using the telephone numbers I provided in
paragraph 2 of this form. It is very important that I let the Department know if any of my
contact information changes. If I do not let the Department know of any of my contact
information changes, I understand that I may not receive notification from the
Department if this Consent is void or if someone other than the specified person or
persons files a petition to adopt my child. If any of my contact information changes, I
should immediately notify:
Caseworker’s name and telephone number:
______________________________________________________________________________
Agency name, address, zip code and telephone number:
______________________________________________________________________________
Supervisor’s name and telephone number:
______________________________________________________________________________
DCFS Advocacy Office for Children and Families: 1-800-232-3798 or 1-217-524-2029
12. I expressly acknowledge that paragraph 9 (and paragraphs 8a and 8b, if applicable) does
not impair the validity and finality of this Consent under any circumstance.
13. I have read and understand the above and I am signing it as my free and voluntary act.
Dated this ___________________________ day of ___________________________, 20 _____
__________________________________________
Signature
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.4
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
STATE OF ___________________________ ) CASE NO. ____________________________
)
)
COUNTY OF _________________________ )
CERTIFICATE OF ACKNOWLEDGEMENT OF CONSENT
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A
SPECIFIED PERSON OR PERSONS: DCFS CASE
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, DCFS case, appeared
before me this day in person and acknowledged that (she) (he) signed and delivered such
Consent as a free and voluntary act, for the specified purpose.
I have fully explained that by signing this consent this parent is irrevocably and permanently
relinquishing all parental rights to the child so that the child may be adopted by a specified
person and persons, and this parent has stated that such is (her) (his) intention and desire. I have
fully explained that this consent is void only if:
1. The placement is disrupted and the child is moved to a different placement; or
2. A court denies the petition for adoption; or
3. The Department of Children and Family Services Guardianship Administrator refuses to
consent to the child’s adoption by a specified person or persons on the basis that the
adoption is not in the child’s best interests.
Dated this ________ day of _________________, 20 _______.
___________________________________________________
Signature
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.5
STATE OF ___________________________ )
) SS.
COUNTY OF _________________________ )
ACKNOWLEDGEMENT OF SIGNATURE
I, _________________________________________________, Notary Public, in and for said
County and State, to hereby certify that _____________________________________________,
personally known to me to be the same person whose name is subscribed in the foregoing
Certificate of Acknowledgement, appeared before me in person this date and acknowledged that
(she) (he) signed such as (her) (his) free and voluntary act and that the statements made in said
certificate are true.
Given under my hand a notarial seal this ________ day of ______________________, 20 _____.
_________________________________________ Notary Public
(Seal)
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.6
BIRTH PARENT RIGHTS AND RESPONSIBILITIES-PRIVATE
FORM (750 ILCS 50/10)
As a birth parent in the State of Illinois, you have the right:
1. To have our own attorney represent you. The prospective adoptive parents may agree to
pay for the cost of your attorney in a manner consistent with Illinois law, but they are not
required to do so.
2. To be treated with dignity and respect at all times and to make decisions free from
coercion and pressure.
3. To receive counseling before and after signing a Final and Irrevocable Consent to
Adoption (“Consent”), a Final and Irrevocable Consent to Adoption by a Specified
Person or Persons: Non-DCFS Case (“Specified Consent”), or a Consent to Adoption of
Unborn Child (“Unborn Consent”). The prospective adoptive parents may agree to pay
for the cost of counseling in a manner consistent with Illinois law, but they are not
required to do so.
4. To ask to be involved in choosing your child’s prospective adoptive parents and to ask to
meet them.
5. To ask your child’s prospective adoptive parents any questions that pertain to your
decision to place your child with them.
6. To see your child before signing a Consent or Specified Consent.
7. To request contact with your child and/or the child’s prospective adoptive parents, with
the understanding that any promises regarding contact with your child or receipt of
information about the child after signing a Consent, Specified Consent, or Unborn
Consent cannot be enforced under Illinois law.
8. To receive copies of all documents that you sign and have those documents provided to
you in your preferred language.
9. To request that your identifying information remain confidential, unless required
otherwise by Illinois law or court order, and to register with the Illinois Adoption
Registry and Medical Information Exchange.
10. To work with an adoption agency or attorney of your choice, or change said agency or
attorney, provided you promptly inform all of the parties currently involved.
11. To receive, upon request, a written list of any promised support, financial or otherwise,
from your attorney or the attorney for your child’s prospective adoptive parents.
Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.7
12. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready
to do so.
13. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have
received financial support from the prospective adoptive parents.
If you do not receive any of the rights described in this Form, it shall not be a basis to revoke
Consent, Specified Consent, or Unborn Consent.
As a Birth Parent in the State of Illinois, you have the responsibility:
1. To carefully consider your reasons for choosing adoption.
2. To voluntarily provide all known medical, background, and family information about
yourself and your immediate family to your child’s prospective adoptive parents or their
attorney. For the health of your child, you are strongly encouraged, but not required, to
provide all known medical, background, and family history information about yourself
and your family to your child’s prospective adoptive parents or their attorney.
3. (Birth mothers only) To accurately complete an Affidavit of Identification, which
identifies the father of the child when known, with the understanding that a birth mother
has a right to decline to identify the birth father.
4. To not accept financial support or reimbursement of pregnancy related expenses
simultaneously from more than one source.
______________________________________
Initials
Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.1
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
IN THE MATTER OF THE ADOPTION OF: ) CASE NO. _______________________________
)
)
____________________________________ )
A Minor
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY
A SPECIFIED PERSON OR PERSONS: NON-DCFS CASE
I, _______________________________________________________ state:
1. That I am the mother/father of _______________________________________________
a male/female child born on ___________________________________________, at
________________________________, City of ________________________________
and State of _____________________________.
2. That I reside at _______________________________________________, County of
____________________________ and State of ________________________________.
3. That I am the age of ____________________ years.
4. That I hereby enter my appearance in this proceeding and waive service of summons on
me.
5. That I hereby acknowledge that I have been provided a copy of the Birth Parents Rights
and Responsibilities-Private Form before signing this Consent and that I have had time
to read, or have had read to me, this Form and that I understand the Rights and
Responsibilities described in this Form. I understand that if I do not receive any of my
rights as described in said Form, it shall not constitute a basis to revoke this Final and
Irrevocable Consent to Adoption by a Specified Person.
6. That I do hereby consent and agree to the adoption of such child by ________________
______________________________________________________________ (specified
person or persons) only.
7. That I wish to and understand that upon signing this consent I do irrevocably and
permanently give up all custody and other parental rights I have to such child if such
child is adopted by ______________________________________________________
(specified person or persons). I hereby transfer all of my rights to the custody, care and
control of such child to ___________________________________________________
___________________________________ (specified person or persons).
8. That I understand such child will be adopted by ________________________________
___________________________________ (specified person or persons) and that I
cannot under any circumstances, after signing this document, change my mind and evoke
Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.2
or cancel this consent or obtain or recover custody or any other rights over such child if
________________________________________________________________________
(specified person or persons) adopt(s) such child; PROVIDED that each specified person
has filed, or shall file, within 60 days from the date hereof, a petition for the adoption of
such child.
9. That if the specified person or persons designated herein do not file a petition for
adoption within the time-frame specified above, or, if said petition for adoption is filed
within the time-frame specified above but the adoption petition is dismissed with
prejudice or the adoption proceeding is otherwise concluded without an order declaring
the child to be the adopted child of the specified person or persons, then I understand that
I will receive written notice of such circumstances within 10 business days of their
occurrence. I understand that the notice will be directed to me using the contact
information I have provided in this Consent. I understand that I will have 10 business
days from the date that the written notice is sent to me to respond, within which time I
may request the Court to declare this Consent voidable and return the child to me. I
further understand that the Court will make the final decision of whether or not the child
will be returned to me. If I do not make such request within 10 business days of the date
of the notice, then I expressly waive any other notice or service of process in any legal
proceeding for the adoption of the child.
10. That I expressly acknowledge that nothing in this Consent impairs the validity and
absolute finality of this Consent under any circumstance other than those described in
paragraph 9 of this Consent.
11. That I understand that I have a remaining duty and obligation to keep _______________
_________________________________________________________ (insert name and
address of the attorney for the specified person or persons) informed of my current
address or other preferred contact information until this adoption has been finalized. My
failure to do so may result in the termination of my parental rights and the child being
placed for adoption in another home.
12. That I do expressly waive any other notice or service of process in any of the legal
proceedings for the adoption of the child as long as the adoption proceedings by the
specified person or persons is pending.
13. That I have read and understand the above and I am signing it as my free and voluntary
act.
14. That I acknowledge that this Consent is valid even if the specified person or persons
separate or divorce or one of the specified persons dies prior to the entry of the final
judgment for adoption.
___________________________________ ____________________________________
Signature of Biological Parent Phone Number(s) of Biological Parent
___________________________________ ____________________________________
Address of Biological Parent Personal email(s) of Biological Parent
Dated this ______ day of __________________ 20 ______, at _________o’clock a.m. / p.m.
Final & Irrevocable Consent to Adoption-Non-DCFS
Rev. 04-01-16/p.3
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
STATE OF _____________________________ ) CASE NO. ____________________________
)
)
COUNTY OF ___________________________ )
CERTIFICATE OF ACKNOWLEGEMENT OF CONSENT FINAL AND
IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR
PERSONS: NON-DCFS CASE
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, non-DCFS case,
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 am further satisfied that,
before signing this Consent, _______________________________________________________
has read, or has had read to him/her, the Birth Parent Rights and Responsibilities-Private Form.
I have fully explained that by signing such Consent she/he is irrevocably relinquishing all
parental rights to such child and she/he has stated that such is her/his intention and desire.
__________________________________ ______________________________________
Date Judge
Seal of the Court
Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.4
BIRTH PARENT RIGHTS AND RESPONSIBILITIES-PRIVATE
FORM (750 ILCS 50/10)
As a birth parent in the State of Illinois, you have the right:
1. To have our own attorney represent you. The prospective adoptive parents may agree to
pay for the cost of your attorney in a manner consistent with Illinois law, but they are not
required to do so.
2. To be treated with dignity and respect at all times and to make decisions free from
coercion and pressure.
3. To receive counseling before and after signing a Final and Irrevocable Consent to
Adoption (“Consent”), a Final and Irrevocable Consent to Adoption by a Specified
Person or Persons: Non-DCFS Case (“Specified Consent”), or a Consent to Adoption of
Unborn Child (“Unborn Consent”). The prospective adoptive parents may agree to pay
for the cost of counseling in a manner consistent with Illinois law, but they are not
required to do so.
4. To ask to be involved in choosing your child’s prospective adoptive parents and to ask to
meet them.
5. To ask your child’s prospective adoptive parents any questions that pertain to your
decision to place your child with them.
6. To see your child before signing a Consent or Specified Consent.
7. To request contact with your child and/or the child’s prospective adoptive parents, with
the understanding that any promises regarding contact with your child or receipt of
information about the child after signing a Consent, Specified Consent, or Unborn
Consent cannot be enforced under Illinois law.
8. To receive copies of all documents that you sign and have those documents provided to
you in your preferred language.
9. To request that your identifying information remain confidential, unless required
otherwise by Illinois law or court order, and to register with the Illinois Adoption
Registry and Medical Information Exchange.
10. To work with an adoption agency or attorney of your choice, or change said agency or
attorney, provided you promptly inform all of the parties currently involved.
11. To receive, upon request, a written list of any promised support, financial or otherwise,
from your attorney or the attorney for your child’s prospective adoptive parents.
12. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready
to do so.
Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.5
13. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have
received financial support from the prospective adoptive parents.
If you do not receive any of the rights described in this Form, it shall not be a basis to revoke
Consent, Specified Consent, or Unborn Consent.
As a Birth Parent in the State of Illinois, you have the responsibility:
1. To carefully consider your reasons for choosing adoption.
2. To voluntarily provide all known medical, background, and family information about
yourself and your immediate family to your child’s prospective adoptive parents or their
attorney. For the health of your child, you are strongly encouraged, but not required, to
provide all known medical, background, and family history information about yourself
and your family to your child’s prospective adoptive parents or their attorney.
3. (Birth mothers only) To accurately complete an Affidavit of Identification, which
identifies the father of the child when known, with the understanding that a birth mother
has a right to decline to identify the birth father.
4. To not accept financial support or reimbursement of pregnancy related expenses
simultaneously from more than one source.
______________________________________
Initials
Consent to Adoption of Unborn Child/p.1
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_________________________________ CASE NO. ______________________________
_________________________________
Petitioner
vs.
_________________________________
_________________________________
Defendant
CONSENT TO ADOPTION OF UNBORN CHILD I, ________________________________________________, state:
(name of father)
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 hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and
Responsibilities-Private Form before signing this Consent, and that I have had time to read, or have had
read to me, this Form. I understand that if I do not receive any of the rights as described in this Form, it
shall not constitute a basis to revoke this Consent to Adoption of Unborn Child.
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 this ________ day of _________________________, 20_____.
_________________________________________
(Signature)
Consent to Adoption of Unborn Child/p.2
Rev. 04-01-16
STATE OF ILLINOIS )
) SS.
COUNTY OF DEKALB )
I, ____________________________________________________________________________, (name and official title)
do hereby certify 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.
In Witness Whereof, I have hereunto affixed my signature this ______ day of ______________,
20 _____.
STATE OF ILLINOIS )
) SS.
COUNTY OF DEKALB )
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 acknowledgement, 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 said certificate are true.
Given under my hand and notarial seal this ______ day of __________________, 20____.
(OFFICIAL SEAL) ______________________________ Notary Public
Consent to Adoption of Unborn Child/p.3
Rev. 04-01-16
BIRTH PARENT RIGHTS AND RESPONSIBILITIES-PRIVATE
FORM (750 ILCS 50/10)
As a birth parent in the State of Illinois, you have the right:
1. To have our own attorney represent you. The prospective adoptive parents may agree to
pay for the cost of your attorney in a manner consistent with Illinois law, but they are not
required to do so.
2. To be treated with dignity and respect at all times and to make decisions free from
coercion and pressure.
3. To receive counseling before and after signing a Final and Irrevocable Consent to
Adoption (“Consent”), a Final and Irrevocable Consent to Adoption by a Specified
Person or Persons: Non-DCFS Case (“Specified Consent”), or a Consent to Adoption of
Unborn Child (“Unborn Consent”). The prospective adoptive parents may agree to pay
for the cost of counseling in a manner consistent with Illinois law, but they are not
required to do so.
4. To ask to be involved in choosing your child’s prospective adoptive parents and to ask to
meet them.
5. To ask your child’s prospective adoptive parents any questions that pertain to your
decision to place your child with them.
6. To see your child before signing a Consent or Specified Consent.
7. To request contact with your child and/or the child’s prospective adoptive parents, with
the understanding that any promises regarding contact with your child or receipt of
information about the child after signing a Consent, Specified Consent, or Unborn
Consent cannot be enforced under Illinois law.
8. To receive copies of all documents that you sign and have those documents provided to
you in your preferred language.
9. To request that your identifying information remain confidential, unless required
otherwise by Illinois law or court order, and to register with the Illinois Adoption
Registry and Medical Information Exchange.
10. To work with an adoption agency or attorney of your choice, or change said agency or
attorney, provided you promptly inform all of the parties currently involved.
11. To receive, upon request, a written list of any promised support, financial or otherwise,
from your attorney or the attorney for your child’s prospective adoptive parents.
Consent to Adoption of Unborn Child/p.4
Rev. 04-01-16
12. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready
to do so.
13. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have
received financial support from the prospective adoptive parents.
If you do not receive any of the rights described in this Form, it shall not be a basis to revoke
Consent, Specified Consent, or Unborn Consent.
As a Birth Parent in the State of Illinois, you have the responsibility:
1. To carefully consider your reasons for choosing adoption.
2. To voluntarily provide all known medical, background, and family information about
yourself and your immediate family to your child’s prospective adoptive parents or their
attorney. For the health of your child, you are strongly encouraged, but not required, to
provide all known medical, background, and family history information about yourself
and your family to your child’s prospective adoptive parents or their attorney.
3. (Birth mothers only) To accurately complete an Affidavit of Identification, which
identifies the father of the child when known, with the understanding that a birth mother
has a right to decline to identify the birth father.
4. To not accept financial support or reimbursement of pregnancy related expenses
simultaneously from more than one source.
______________________________________
Initials
Surrender of Unborn Child for Adoption/p.1 Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_________________________________ CASE NO. __________________________
_________________________________
Petitioner
vs.
_________________________________
_________________________________
Defendant
SURRENDER OF UNBORN CHILD FOR PURPOSES OF ADOPTION I, _____________________________________________________, state:
(father)
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 do hereby surrender and entrust the entire custody and control of such child to 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, 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
judgment of said Agency, may be for the best interests of such child, including authorizing medical,
surgical and dental care and treatment including inoculation and anesthesia 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.
Surrender of Unborn Child for Adoption/p.2 Rev. 04-01-16
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 this ________ day of _________________________, 20_____.
________________________________
(Signature)
____________________________________
Witness
____________________________________
Date
STATE OF ILLINOIS )
) SS.
COUNTY OF DEKALB )
I, ___________________________________________________________________________________________, (name and official title)
do hereby certify that ___________________________________________, 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.
In Witness Whereof, I have hereunto affixed my signature this ______ day of ____________________, 20
_____.
STATE OF ILLINOIS )
) SS.
COUNTY OF DEKALB )
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 acknowledgement, 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 said certificate are true.
G iven under my hand and notarial seal this ______ day of ____________________________, 20____.
(OFFICIAL SEAL) _______________________________________
Notary Public
Adoption Notice
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
)
)
)
)
)
)
)
)
CASE NO. _______________________________
ADOPTION NOTICE
In the Matter of the Petition for Adoption of _______________________________________________, a
male/ female child, Adoption No.:________________________.
TO: _______________________________________________________________________________________
____________________________________________________________________________________________________
(whom it may concern or the named parent)
TAKE NOTICE that a Petition was filed in the Circuit Court of DeKalb County, Illinois, for the adoption of a child
named ________________________________________________________________.
NOW THEREFORE, unless you, _________________________________________________________________,
and all whom it may concern, file your Answer to the Petition in said suit or otherwise file your appearance therein, in the said
Circuit Court of DeKalb County, 133 West State Street, Room 203, in the City of Sycamore, Illinois, on or before the
____________ day of _____________________________, 20_____, a default may be entered against you at any time after
that day and a judgment entered in accordance with the prayer of said Petition.
DATED at Sycamore, Illinois, this __________ day of ___________________________, 20_____.
__________________________________________________
Clerk of the Circuit Court
Attorney for Petitioner(s):
Name: ___________________________________________
Address: ___________________________________________
City/State/Zip: ___________________________________________
Telephone No.: ___________________________________________
To be published at least once in each week for three successive weeks, with the first publication being at least 30 days prior to the return date stated above.
Publisher: Please send __________ copies of this publication to the above-named Clerk as soon as possible.
Affidavit for Publication
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_______________________________________________
_______________________________________________
Petitioner(s),
vs.
_______________________________________________
_______________________________________________
Respondent(s).
)
)
)
)
)
)
)
)
)
)
CASE NO. ___________________________________
AFFIDAVIT FOR PUBLICATION
Petition for Adoption of a Child named _______________________________________
___________________________________________________________________________________, being first duly sworn, says
he/she is (a) _________________________________________________________________________________ and further states:
1. That the Respondent (b) ________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2. That the Respondent reside(s) (c) ________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________
__________________________________________________________
Subscribed and sworn to before me this ________ day of
__________________________, 20________________.
______________________________________________
Notary Public
(a) Insert name of “Petitioner” or “Attorney for Petitioner”
(b) Insert correct facts as set forth in Chap. 110, Par. 14, I.R.S.
(c) Insert address of non-resident Respondent when known.
Affidavit
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
IN RE:
ADOPTION OF _____________________________________
)
)
)
CASE NO.___________________________
AFFIDAVIT
__________________________________________________________ on oath, and under penalty of perjury, states:
1. That Affiant is involved in the adoption as:
a) Agency: _________________________________________
b) Natural parents of child sought to be adopted.
c) Petitioner.
d) Attorney.
e) Other.
2. Affiant has:
a) been given
b) been promised
c) received
d) paid
e) promised to pay
the following in connection with this adoption:
Hospital: $________
Physician:
$________
Medicine:
$________
Other Medical Expenses:
$________
Maternity Home:
$________
Agency Fee:
$________
Attorney’s Fees:
$________
Court Costs:
$________
Guardian ad Litem Fees:
$________
Other:
$________
___________________________________________
(Affiant)
Subscribed and sworn to before me on this date:
_____________________________________.
_____________________________________
Notary Public
Certificate of Mailing
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS __________________________________ ) CASE NO. ______________________________
)
_______________________________ ) Petitioner(s), )
vs. )
__________________________________ )
) Petition for the Adoption of a Child Named:
__________________________________ )
Respondent(s). ) _______________________________________
CERTIFICATE OF MAILING
I, ________________________________________ (Deputy) Clerk of the Circuit Court of the County of
DeKalb and State of Illinois, do hereby certify that on the __________ day of ________________________,
________, I deposited in the United States mail at ___________, Illinois, a true copy of the Publication Notice in
said cause hereto attached, enclosed in an envelope properly sealed, postage prepaid and correctly addressed, to
each of the following-named persons at the respective address shown opposite each name:
NAME RESIDENCE ADDRESS
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I further certify that said mailing was made with ten (10) days of the publication of said notice.
WITNESS the hand of said Clerk and the seal of said Court
hereto affixed this date ________________________________. ___________________________________________________ (Clerk)
Order Appointing Guardian Ad Litem
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
In The Interest Of
______________________________, a minor
)
)
)
)
)
CASE NO. _________________________________
ORDER APPOINTING GUARDIAN AD LITEM
This cause now coming on to be heard upon the Petition of______________________________.
It appears to the Court that it is in the best interest of the minor to appoint a Guardian ad Litem.
THEREFORE, IT IS HEREBY ORDERED BY THIS COURT, that _____________________
________________________, is appointed Guardian ad Litem for the said minor _________________
____________________________ to make answer unto said Petition, to represent said minor in this
proceeding, to be and appear upon the hearing of said Petition in this Court, and defend the rights and
interests of said minor in said cause. That said Guardian ad Litem shall have the power and authority to
consent to the adoption of said child should such Guardian ad Litem see fit to do so.
Dated______________________, 20_____
___________________________________
Judge
Answer of Guardian Ad Litem
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
In The Interest Of
______________________________, a minor
)
)
)
)
)
CASE NO. _________________________
ANSWER OF GUARDIAN AD LITEM
______________________________________________________________________, a minor by
____________________________________________________, Guardian ad Litem, answers unto
said Petition say______ that ____________ is not advised of the matters and things in said Petition
contained, and neither admit nor deny them, and respectfully demand that said Petitioner______ be
strictly required to prove the allegations in said Petition.
Dated_________________________, 20_____
______________________________________
(Guardian Ad Litem)
Name: ______________________________________
Attorney for: ______________________________________
Address: ______________________________________
City, State, Zip: ______________________________________
Telephone: ______________________________________
Interim Order-Adoption / p.1
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
_________________________________ ) CASE NO. _______________________________
_________________________________ )
Petitioner(s), )
)
vs. )
__________________________________ )
__________________________________ )
Respondent(s).
INTERIM ORDER
The Petition of _____________________________________________________________, having been filed
herein on the____ day of _____________, 20_____, for the adoption of______________________________________,
a minor child;
And it appearing to the court that the child sought to be adopted herein is a minor, and that the court should
therefore appoint a Guardian ad Litem to represent the interests of said child in this proceeding;
IT IS THEREFORE ORDERED that _________________________________________________________,
a duly licensed attorney under the laws of the State of Illinois and a member of this bar, be and hereby is appointed as
Guardian ad Litem to represent the interests in this proceeding of _________________________________________,
the minor child sought to be adopted herein.
And it further appearing to the court that all of the other Respondent(s) to this cause are of full legal age and
under no legal disability, except _____________________________________________________________________
_______________________________________________________________________________________________,
who is/are: ______________________________________________________________________________________
_______________________________________________________________________________________________,
and that the court should therefore appoint a Guardian ad Litem to represent the interests in this proceeding of said
Respondent(s).
IT IS THEREFORE ORDERED that ________________________________________________________, a
duly licensed attorney under the laws of the State of Illinois, and a member of this bar, be and hereby is appointed as
Guardian ad Litem to represent the interests in this proceeding of said Respondent, _____________________________
_____________________________________________________________________________________________.
And said Petition now coming on for preliminary hearing as provided by Section 13 of the Illinois Adoption
Act, and the court being now fully advised in the premises, DOTH FIND:
Interim Order-Adoption / p.2
Rev. 04-01-16
1. That written consents to the adoption of said child by Petitioner(s) have been executed and filed herein by
the following named persons, and/or agency___________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
____________________________________________________________________________________________
that all of said consents have been executed according to law, and are valid and binding.
2. (a) That _________________________________________________________________________
is/are willing to accept and assume temporary custodial care of the child sought to be adopted herein, pending a final
determination of this cause; that such temporary custodial care is suitable and proper for the welfare of said child.
(b) That it is in the best interests of said child that the custodial rights of his/her parents be terminated,
and that said child be temporarily committed to the care and custody of some competent person or agency pending a
final determination of this cause; that _____________________________________________________________ is a
suitable, proper and competent person/agency, and that it will be for the welfare of said child that he/she be temporarily
committed to the care and custody of the said ________________________________________________________,
pending a final determination of this cause.
IT IS THEREFORE ORDERED, ADJUDGED and DECREED by the court as follows:
1. That the custodial rights of the parents of said child be and they are hereby terminated, and that said child
be and he/she is hereby declared to be a ward of this court.
2. That said child be and he/she is hereby committed to the temporary care and custody of
___________________________________________________________________, pending a final determination of
this cause.
3. _________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
____________________________________________________________________________________________
ENTERED this __________ day of _______________________________, 20_____.
____________________________________________________
Judge
Supplementary Interim Order
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
IN THE MATTER OF ) CASE NO. ____________________________
)
BABY (BOY / GIRL) )
)
_____________________________________ )
SUPPLEMENTARY INTERIM ORDER
In accordance with Interim Order entered herein on ____________________________________
and impounded,
IT IS HEREBY ORDERED that _________________________________________ (institution)
deliver custody of the above-entitled child to _______________________________________________,
Child Welfare Worker of DeKalb County, Illinois, for temporary custody placement by her/him in
accordance with above Interim Order.
IT IS FURTHER ORDERED that the Clerk of the Circuit Court be authorized to make a certified
copy of this Supplemental Interim Order only.
DATED: ______________________________
_____________________________________________
Judge
Order for Investigation
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
__________________________________________________
__________________________________________________
Petitioner(s),
vs.
__________________________________________________
__________________________________________________
Respondent(s).
)
)
)
)
)
)
)
)
)
)
)
CASE NO. _____________________________
ORDER FOR INVESTIGATION
IT IS HEREBY ORDERED BY THE COURT that ______________________________________, be,
and hereby is, specifically designated to investigate, accurately, fully and promptly the allegations contained in
the Petition heretofore filed, and also the character, reputation and general standing in
______________________________________________ community of the Petitioner(s), the religious faith of
the Petitioner(s), and if ascertainable, of the child sought to be adopted, and also whether the Petitioner(s) is/are a
proper person(s) to adopt the child named in the Petition on file herein and whether the said child is a proper
subject of adoption.
IT IS FURTHER ORDERED BY THE COURT THAT ___________________________________,
reduce to writing the information obtained as the result of such investigation and present the same to the Court on
or before the return day designated in the Summons issued in this proceeding.
IT IS FURTHER ORDERED BY THE COURT that the costs of such investigation be charged to
____________________________________________________.
ENTERED this _____ day of ____________________, 20_____.
_______________________________________
Judge
Decree of Adoption/p.1
Rev. 04-01-16
IN THE CIRCUIT COURT OF THE TWENTY-THIRD
JUDICIAL CIRCUIT
DEKALB COUNTY, ILLINOIS
______________________________________________
______________________________________________
Petitioner(s),
vs.
______________________________________________
______________________________________________
Respondent(s).
)
)
)
)
)
)
)
)
)
)
CASE NO. ______________________________
DECREE OF ADOPTION
This cause coming on to be heard upon the verified Petition of ____________________________________ for
the adoption of ___________________________________________________, hereinafter sometimes referred
to as the “child,” and ____________________________________________________________ the court being
fully advised in the premises finds as follows:
(1) Respondent(s) is/are all the person(s) entitled to be notified of the within proceeding and have been
so notified in the following manner: ____________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(2) Valid properly acknowledged consents to the adoption of said child and have been filed as required
by an Act of the General Assembly of the State of Illinois entitled “An Act in Relation to the Adoption of
Persons and to Repeal an Act Therein Named,” approved July 17, 1959, as follows:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(2-a) Consents to the adoption of said child have not been filed for the following reasons:
__________________________________________________________________________________________
__________________________________________________________________________________________
(3) It appearing to the court that ________________________________________________________
Respondent(s) are in the military service of the United States, or that their military status is unknown,
thereupon the court appointed ________________________________________________________________,
attorney of record for such Respondent(s) or those who may be in the military service of the United States.
Decree of Adoption/p.2
Rev. 04-01-16
(4) The court heretofore appointed _____________________________________________________
Guardian ad Litem of said child.
(5) On ___________________________, 20_____, the court appointed ________________________
to make the investigation required to be made under the provisions of said Act as to the allegations contained in
said Petition, the character, reputation and general standing in the community of the Petitioner(s), the religious
faith of the Petitioner(s) and, if ascertainable, of said child, whether Petitioner(s) are proper persons to adopt
said child and whether said child is a proper subject of adoption. The said ____________________________
______________________ has made a report of said investigation to the court which report the court approves.
(6) On ___________________________, 20_____, which was at a time as soon as practical after the
filing of said Petition, the court held a hearing for the purpose of complying with Section 13 of said Act and, as
shown by the records kept by the Clerk of this Court, the hearing thereof and the order or orders entered by the
court complied with said Section 13.
(7) Said child not being a related child, one of the orders referred to in Par. 6 hereof was an Interim
Order entered ___________________________, 20_____, vesting temporary care, custody and control of the
child to the Petitioner(s).
(8) Upon this ___________ day of _______________________, 20_____, Petitioner(s) have applied
to this court for the entry of a Decree of Adoption. Notice of said application was served by Petitioner(s) upon
the following agency or person and at the following time and manner: _________________________________
__________________________________________________________________________________________
(9) A hearing was held upon said application on __________________________________________,
20_____, at which Petitioner(s) and the child appeared.
(9-A) A hearing was held upon said application on _____________________________, 20______, at
which hearing __________________________________________________________________ did not appear
because such appearance was waived by the court for good cause shown which was as follows:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(10) The court is satisfied from the report referred to in par. 5 hereof and from the evidence introduced
at said hearing that the adoption is for the welfare of said child and that the consents for adoption referred to in
Par. 2 hereof are valid and have been filed by all persons required to do so under the provisions of said Act in
order for the court to enter this Decree.
(10-A) The court is satisfied from the report referred to in par. 5 hereof and from the evidence
introduced at said hearing that the adoption is in the best welfare of said child and that no consent for adoption
is required as provided in Section 8 of said Act for the reasons given in par. 2-A hereof.
Decree of Adoption/p.3
Rev. 04-01-16
(11) The evidence given at the aforesaid hearing sustained the allegations of said petition and said
allegations are true.
(12) The said child was born on __________________________________________, 20_____, in the
County of _________________________, State of __________________________. Petitioner(s) reside in the
County of _________________________, State of ___________________. The parents of said child reside as
follows:___________________________________________________________________________________
Petitioner(s) have satisfied all the requirements of said Act to entitle them to adopt said child and are subject to
the jurisdiction of the court in this proceeding under the provisions of the Act. Said child is subject to the
jurisdiction of this court in this proceeding under the provisions of said Act and is entitled to be adopted by
Petitioner(s).
(13) No consent or surrender for adoption was taken until the passage of seventy-two hours after the
birth of the child.
(14) It will be for the welfare of the child to waive the waiting period of six months provided in Section
14 of the Act and grant a Decree of Adoption.
(15) _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________.
NOW, THEREFORE, IT IS ORDERED, ADJUDGED AND DECREED as follows:
(a) The said ________________________________________________________________________
be and hereby is adopted by ___________________________________________________________________
and said __________________________________________________________________________________
be and hereby is the child of __________________________________________________________________.
(b) The name of said child be and hereby is changed to _____________________________________.
(c) The natural parents of said child be and are hereby deprived of all legal rights with respect to said
child and said child be freed from all obligations whatsoever to said natural parents.
Dated ____________________________________, 20_____.
____________________________________________
Judge