Fill and Sign the Minnesota Adoption 497312666 Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type Family Court In the Matter of: Petitioner CONSENT TO ADOPTION vs. Respondent I, , state as follows: 1. I am _______ years of age; and reside at (Street Address) (City) (State) (County) 2. I have been advised _____________________________ is the mother of a ______________ child (Male/Female) named ____________________________ born or expected to be born on _________________ and I have registered with the Father’s Adoption Registry as father. 3. I declare that I am the father. I understand that the mother wishes to consent to the adoption of the child. I consent to the adoption and waive any rights, remedies, and defenses I may have. This consent is being given in order to allow the adoption of the child and so that the court may terminate any rights I may have. 4. I enter my appearance in this case and waive service of summons and other pleading. OATH I have been sworn and say under oath I have read and understand this form. The facts it contains are true and correct to the best of my knowledge. I have signed this document freely and voluntarily. Sworn/affirmed before me this _________ of _____________, _______ Notary Public/Court Deputy ADO101 State ENG Rev 9/99 www.mncourts.gov/forms Page 1 of 2Signature: Sign only in presence of notary or court clerk Print Name: Street Address: City/State/Zip: Telephone: (______) ACKNOWLEDGEMENT Pursuant to Minnesota Statute § 549.21, the undersigned acknowledges that costs, disbursements, and reasonable attorney and witness fees may be awarded to the opposing party or parties for actions in bad faith; the assertion of a claim or a defense that is frivolous and that is costly to the other party; the assertion of an unfounded position solely to delay the ordinary course of the proceedings or to harass; or the commission of a fraud upon the Court. Dated: VERIFICATION STATE OF MINNESOTA ) ) ss. COUNTY OF ) , being duly sworn upon oath, deposes and says that she is the Petitioner in the above-entitled action; that she has read the foregoing Petition and knows the contents thereof; that the same is true of her knowledge except as to those matters therein stated on information and belief, and as to those matters she believes them to be true. Sworn/affirmed before me this _________ of _____________, _______ Notary Public/Court Deputy ADO101 State ENG Rev 9/99 www.mncourts.gov/forms Page 2 of 2Signature: Sign only in presence of notary or court clerk Print Name: Street Address: City/State/Zip: Telephone: (______)