CONSENT
BY UNMARRIED MOTHER
I,
_______________________________, (name of parent) residing at _____________
________________________________________
(address), do hereby relinquish and forever release to
___________________________, (name) residing at ____________
___________________________________
(address), all my rights and responsibilities as parent to my _____________
(male/female) child ___________________________ (name), born at
_________________________________________________________ (hospital or clinic
name and address) on __________________ (month & day), ______ (year), which
said child was born out of wedlock.
I
hereby assert that I am the natural mother of the above-named child, who has
reached the age of _______________ (_____) days, and that I relinquish unto the
above-named __________________________________ (name), all my rights and
privileges to said child, and, therefore, I respectfully request any court of
competent jurisdiction to enter its order of adoption.
This
release is made pursuant to _________________ (cite statute or other
authority).
In
witness whereof, I have signed this instrument at ____________________________
(place of execution) on _____________________ (month & day), ________
(year).
____________________________________________
(Signature)
This
document was hereby signed in the presence of the following:
______________________________________ __________________
______________________________________ __________________
(Signature(s))
(Date(s))
