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State of Alabama Unified Judicial System Page 1 of 3 Form PR-2 8/08 CONSENT FOR ADULT TO BE ADOPTED (Section 26-10A-11(b), Ala.Code 1975) Probate Court Case No.: STATE OF ALABAMA ___________________COUNTY In the Matter of the Adoption Petition of [Full Name(s) and Age(s) of Petitioner(s) and His/Her/Their Residence Address(es), Including City(ies) or Town(s), State(s), and Zip Code(s)] : _______________________________________________________________________________ _______________________________________________________________________________. To Adopt ____________________________________________________ (Name of Person), an Adult. KNOW ALL MEN BY THESE PRESENTS that I, __________________________________ _________________________________________, as ( Check which boxes are applicable): [ the person being adopted; OR [ ] the spouse or [ ] the guardian or [ the conservator of the person being adopted; OR [ ] the guardian ad litem appointed by this Court for the person being adopted (having filed a written report), after been first duly placed under oath, do hereby state, agree, and consent to [ ] my adoption [ ] the adoption of _________________________ ( Name of person being adopted ) by _________________________________ [ Name(s) of Petitioner(s), unless identity waived ] in order that the person being adopted may have all the privileges which may be accorded to the person by the laws of Alabama upon his or her legal adoption. The Petitioner(s) further aver(s) as follows (Check which boxes are applicable): [ 1. That the person being adopted is _____ years of age, having been born on ____________________________ (state month, day, and year of birth). [ 2. Any Other Name(s) by Which the Person Being Adopted Has Been Known: _________________________________________________________________________________. [ 3. That a copy of the Petition for Adoption of the person was received and that [ Check which boxes are applicable ]: [ ] the person being adopted has read the Petition and understands its content and purpose; OR the [ spouse, [ ] guardian, [ conservator, or [ guardian ad litem has read the Petition and understands its content and purpose; [ 4. As the: [ ] person being adopted; OR the [ ] spouse, [ ] guardian, [ ] custodian, or [ ] guardian ad litem of the person being adopted, I am executing this document voluntarily and unequivocally thereby consenting to the adoption. [ 5. I, as the [ ] person being adopted; OR the [ ] spouse, [ ] guardian, [ ] custodian, or [ ] guardian ad litem of the person being adopted, understand that by signing this document and the subsequent court order to ratify the consent, I will forfeit all rights and obligations and that I understand the consent to the adoption and execute it freely and voluntarily. [ 6. I understand that the consent to the adoption may be irrevocable, and I should not execute it if I need or desire psychological or legal advice, guidance, or counseling. State of Alabama Unified Judicial System Page 2 of 3 Form PR-2 8/08CONSENT FOR ADULT TO BE ADOPTED (Section 26-10A-11(b), Ala.Code 1975) [ ] 7. I, as the [ ] person being adopted; OR the [ ] spouse, [ ] guardian, [ ] custodian, or [ ] guardian ad litem of the person being adopted, have received or have been offered a copy of this document. [ ] 8. I, as the [ ] person being adopted; OR the [ ] spouse, [ ] guardian, [ ] custodian, or [ ] guardian ad litem, am voluntarily waiving the right to know the identity of each petitioner who petitions to adopt the person by executing this consent. [ 9. I, as the [ ] person being adopted; OR the [ ] spouse, [ ] guardian, [ ] custodian, or [ ] guardian ad litem of the person being adopted, waive further notice of the adoption proceedings by the execution of this consent, unless there is a contest or appeal of the adoption proceedings. [ 10. I understand that notice of withdrawal of this consent must be mailed to ___________________ ( county where the consent or petition is filed, if known ) Probate Court at the following address; OR _________________________________________________________________( name and address of agency with whom document is filed); OR _______________________________________________ (name of the petitioner(s) or his/her/their attorney, if the county where the petition was filed is unknown) and that such withdrawal must be mailed within five days of the execution of this document. [ ] 11. That the purpose of this adoption is as follows: ___________________________ _________________________________________________________________________________ (Attach additional sheets, if necessary), and not for any fraudulent purpose. [ ] 12. That a hearing will be conducted by this Court regarding the Petition for Adoption at which hearing the person being adopted, and, if applicable, the spouse, guardian, conservator, or guardian ad litem, will be informed in writing. I do hereby request that Judge of Probate make all orders and decrees as may be necessary or proper to legally effect the adoption. Given under my hand at ____ o’clock [ ] A.M. [ ] P.M. ( time) on _____________________ ( date), at ___________________________________________________________________ ( address of filing) _____________________________________ [Signature of Person Being Adopted, Spouse, Guardian, Conservator, or Guardian ad Litem] I, ____________________________________________, sign my name to this instrument this the _____ day of _______________________, 20 ___, and being first duly sworn, do hereby declare to the undersigned authority that I execute it as my free and voluntary act for the purpose therein expressed, and I am _____ years of age or older, of sound mind, and under no constraint or undue influence. _____________________________________[Signature of Person Being Adopted, Spouse, Guardian, Conservator, or Guardian ad Litem] State of Alabama Unified Judicial System Page 3 of 3 Form PR-2 8/08 CONSENT FOR ADULT TO BE ADOPTED (Section 26-10A-11(b), Ala.Code 1975) STATE OF ___________________________ ______________________________ COUNTY Subscribed, sworn to and acknowledged before me by _____________________________ this _____ day of ___________________, 20 ____. __________________________________ Notary Public (My commission expires: ___________________) I acknowledge receipt of two copies of this document. _____________________________(Seal) _________________________________(Date) NOTICE OF WITHDRAWAL I, ______________________________________________, as [ Check which boxes are applicable]: ] the person being adopted; OR the [ ] spouse, or [ ] guardian, or [ ] conservator of the person being adopted; OR [ ] the guardian ad litem appointed by this Court for the person being adopted, on this ________ day of ______________________, 20___, at _______ [ ] a.m. [ ] p.m.( time of day ) in the presence of two (2) witnesses, whose signatures and addresses are subscribed below, hereby withdraw the Consent to Adoption previously signed by me. __________________________________ [Signature of Person Being Adopted, Spouse, Guardian, Conservato r, or Guardian ad Litem] ________________________________________________ [Printed Name of Witness] ________________________________________________ [Signature of Witness] ______________________________________________________________________________ [Home Address of Witness, including City or Town, State, and Zip Code] ________________________________________________ [Printed Name of Witness] ________________________________________________ [Signature of Witness] ______________________________________________________________________________ [Home Address of Witness, including City or Town, State, and Zip Code]