750 ILCS 50/10 — Illinois Code / Chapter 750 / Act 50 / Section 10
Section 10
Status: in_force

(750 ILCS 50/10) (from Ch. 40, par. 1512) Sec. 10. Forms of consent and surrender; execution and acknowledgment thereof. A. The form of consent required for the adoption of a born child shall be substantially as follows: FINAL AND IRREVOCABLE CONSENT TO ADOPTION I, ...., (relationship, e.g., mother, father, relative, guardian) of ...., a male or female (circle one) 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 (insert date). ......................... If under Section 8 the consent of more than one person is required, then each such person shall execute a separate consent. A-1. (1) The form of the Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case set forth in this subsection A-1 is to be used by legal parents only. This form is not to be used in cases in which there is a pending petition under Section 2-13 of the Juvenile Court Act of 1987. (2) The form of the Final and Irrevocable Consent to Adoption by a Specified Person or Persons in a non-DCFS case shall have the caption of the proceeding in which it is to be filed and shall be substantially as follows: FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR PERSONS; NON-DCFS CASE I, ...., (relationship, e.g., mother, father) of ...., a male or female (circle one) child, state: 1. That such child was born on ...., at ....., in the City/Town of ... and State of .... 2. That I reside at ...., County of .... and State of ...., my email address (if I have one) is .... my cell phone number where I can receive text messages (if I have one) is .... and my land line phone number (if I have one) is ...., and any other contact information is .... 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 hereby acknowledge that I have been provided 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 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. If only first names are used for the specified person or persons, I voluntarily sign this specified consent form without disclosure to me of the last name of the specified person or persons. However, I understand that if I wish to know the last name of the specified person or persons, I may request it before signing the form. If I do not receive the last name, I may choose not to sign the specified consent form. 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 revoke 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 be sent written notice of such circumstances at the mailing address, at the email address, through a text message to my cell phone number, and to any other contact information I have provided in paragraph 2 within 5 business days of this 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 15 business days from the date that the written notice is sent to me to respond in the manner described in the notice, 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 15 business days of the date the notice was sent, then I expressly waive any other notice or service of process in any legal proceeding regarding the child, including a legal proceeding for someone other than ..... (specified person or persons) to adopt the child, and that I will have no parental rights as to the child. The person sending the notice shall file an affidavit of notice as proof of the date sent. 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 proceeding 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. Dated (insert date). ............................................. Signature of parent. ............................................. Address of parent. ............................................. Phone number(s) of parent. ............................................. Personal email(s) of parent. ............................................. (3) The form of the certificate of acknowledgement for a Final and Irrevocable Consent for Adoption by a Specified Person or Persons: Non-DCFS Case shall be substantially as follows: STATE OF ..............) ) SS. COUNTY OF .............) I, .................... (Name of Judge or other person), ..................... (official title, name, and address), certify that ............., personally known to me to be the same person whose name is subscribed to the foregoing Final and Irrevocable Consent for Adoption by a Specified Person or Persons; 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 or her, the Birth Parent Rights and Responsibilities-Private Form. A-2. Birth Parent Rights and Responsibilities-Private Form. The Birth Parent Rights and Responsibilities-Private Form must be read by, or have been read to, any person executing a Final and Irrevocable Consent to Adoption under subsection A, a Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Non-DCFS Case under subsection A-1, or a Consent to Adoption of Unborn Child under subsection B prior to the execution of said Consent. The form of the Birth Parent Rights and Responsibilities-Private Form shall be substantially as follows: Birth Parent Rights and Responsibilities-Private Form THIS FORM DOES NOT CONSTITUTE LEGAL ADVICE. LEGAL ADVICE IS DEPENDENT ON THE SPECIFIC CIRCUMSTANCES OF EACH SITUATION AND JURISDICTION. THE INFORMATION IN THIS FORM CANNOT REPLACE THE ADVICE OF AN ATTORNEY LICENSED IN YOUR STATE. As a birth parent in the State of Illinois, you have the right: 1. To have your 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 request 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 if you are the custodial parent, and to request to see your child if you are not the custodial parent. 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 voluntarily share your medical, background, and identifying information, including information on the original birth certificate of your child. This can be done through the Illinois Adoption Registry and Medical Information Exchange or through completing the Birth Parent Preference Form. Please visit http://dph.illinois.gov or www.newillinoisadoptionlaw.com. 10. To access the Confidential Intermediary Program which provides a way for a court appointed person to connect and/or exchange information between adoptees, adoptive parents and birth parents, and other biological family members, provided in most cases that mutual consent is given. Please visit www.ci-illinois.org or call (800) 526-9022(x29). 11. 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. 12. 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. 13. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready to do so. 14. 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 a 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. (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. 3. To provide the necessary documentation regarding financial need to make an appropriate determination of reasonable pregnancy-related expenses. 4. To not accept financial support or reimbursement of pregnancy related expenses simultaneously from more than one source or if you are not pregnant, as doing so is a crime. 5. 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 do so as set forth on the following form: Birth Parent Medical Information The purpose of this form is to gather your health history, genetic history, and social background information to share with the adoptive parents. It is important the adoptive family provide this information to the child's physician. It will become a part of the child's medical and family history. This form, in its entirety, will be given to the adoptive parent(s). The following information is true and complete to the best of my knowledge and belief. Birth parent name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES or NO (circle one) I agree to release my full name on this form to the adoptive family. If NO is circled then the birth parent's name shall be redacted on this form. MOTHER'S PHYSICAL CHARACTERISTICS: Eyes: ... Hair: .... Complexion: .... Height: .... Weight: .... Body build: ..... Race: ..... Nationality/Descent: ....... Blood type: .... Rh factor: .... Eye glasses or contact lenses? Yes /.../ No /.../ Right /.../ Left /.../ handed Age: .... or Date of birth: ..... Religion: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Please list your highest education level, occupation, hobbies, interests, and talents: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existence of any disabilities? Yes /.../ No /.../ If yes, explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If you have other children, list them below. Include any children previously placed for adoption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Describe your relationship with the birth father: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FATHER'S PHYSICAL CHARACTERISTICS: Eyes: ... Hair: .... Complexion: .... Height: .... Weight: .... Body build: ..... Race: ..... Nationality/Descent: ....... Blood type: .... Rh factor: .... Eye glasses or contact lenses? Yes /.../ No /.../ Right /.../ Left /.../ handed Age: .... or Date of birth: ..... Religion: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Please list your highest education level, occupation, hobbies, interests, and talents: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existence of any disabilities? Yes /.../ No /.../ If yes, explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If you have other children, list them below. Include any children previously placed for adoption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PREGNANCY HISTORY INVOLVING THIS CHILD Month prenatal care began during this pregnancy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications during pregnancy: Yes ... No ... If yes, explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICATION AND OTHER SUBSTANCES USED DURING PREGNANCY OR YEAR PRIOR TO PREGNANCY