made on _________ (Date) between
___________________________, who resides at
here referred to as adopting parent, and _________________________________, who
resides at ______________________________________ (Address), here referred to as adoptee.
parent intends to present to the ______________________________ (Court), a petition in which __________ (He or She) will seek a decree approving
the adoption of adoptee.
parties agree to assume toward each other the legal relation of parent and
child. Adopting parent will henceforth treat adoptee as if _______ (He or She) were the natural child of
adopting parent. Adoptee will
henceforth treat adopting parent as ___________ (His or Her) natural parent. Both parties will have all the rights and be subject to all the
duties and responsibilities of the relation of parent and child.
_______________ (If adopting parent is married, add:
The spouse of adopting parent, ______________________, has executed a written
consent to the adoption agreed to in this instrument, and a copy of that
consent is attached and incorporated by reference.)
witness whereof, the parties have executed this agreement at
___________________ (Designate Place of
Execution) the day and year first above written.