Consent for Adoption

CONSENT FOR ADOPTION

I, having been sworn, state under oath as follows:

1. I, am the birth mother father of the child named above:

2. I am aware of alternatives to adoption, adoption procedures, and opportunities for placement with other adoptive families, and my consent is informed and uncoerced;

3. I have exchanged identifying information with the adoptive parents including but not limited to full names, addresses, physical, mental, social and psychological information and any other information necessary to promote the welfare of the child;

4. I have disclosed to the court any financial agreement or exchange of property between me and the adoptive parents and any fees charged or paid for services related to the placement or adoption of the child; I understand that no binding contract regarding placement or adoption of the child exists;

5. I have been informed of my opportunity to be represented by legal counsel;

a. My counsel is:

b. I have declined to be represented by counsel.

6. I am aware that if I knowingly and intentionally provide false information in writing and under oath which is material to an adoptive placement I shall be guilty of a Class 6 felony under Virginia Code § 63.2-1217; and

7. By signing this consent to adoption, I acknowledge that I do so in the belief that such action will promote the best interest of such child. My consent and signature here are given freely, knowingly, voluntarily, with full knowledge of its meaning and effect, and without any threats, promises, force, improper influence or any other kind of coercion.

I understand that I may revoke this consent, in writing, for any reason, for up to 15 days from the date of my signing this consent. My revocation must be filed with the clerk of the court in which this consent is executed. I understand that my revocation must be filed within 15 days of the signing of this consent and that, if the revocation period expires on a Saturday, Sunday, legal holiday or any day on which the clerk's office is closed as authorized by statute, the revocation period shall be extended to the next day that is not a Saturday, Sunday, legal holiday or other day on which the clerk's office is closed, as authorized by statute.

I further understand that, upon the filing of a valid revocation, the court shall determine custody of my child as between the birth parents.

Given under my hand this date:

Sworn to and subscribed to before me in open court, and in the presence of the adoptive parents, this date:

FORM DC-680 (PAGE ONE OF ONE) REVISED 10/02 PDF