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IN THE CIRCUIT COURT OF COOK COUNTY_ ILLINOIS_1_

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IN THE CIRCUIT COURT OF COOK COUNTY_ ILLINOIS_1_ Powered By Docstoc
					                             IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
                                 COUNTY DEPARTMENT - COUNTY DIVISION

In The Matter of The Petition of                    )
                                                    )
and                                                 )                 No. ____________________
                                                    )
TO ADOPT                                            )
                                                    )

                              FINAL AND IRREVOCABLE CONSENT TO ADOPTION

I, _____________________ (mother/father) of ________________ a ___male child, state:

1. That such child was born on _____________ 19 _____ at __________________ State of ___________________
2. That I reside at _______________________ County of ____________________, State of ___________________
3. That I am of the age of _______________ years.
4. That I hereby enter my appearance in this proceeding and waive service of summons on me.
5. That I do hereby consent and agree to the adoption of such child.
6. 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.
7. That I understand 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.
                                                    Dates this ________ day of ______________ 20________

                                                    _______________________________________________

          I, ________________________, a Judge of the Circuit Court of Cook County, Illinois, 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 at 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 child 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__.

                                                    __________________________________
                                                    Judge of the Circuit Court of Cook County, Illinois
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