Fill and Sign the P 420 Adoption Consent Child 10 or Older State of Alaska Form

Page 1 of 3 P-415 ( 8/17 )(cs ) AS 25.23.060 -.070 ADOPTION CONSENT (PARENT /SPOUSE/GUARDIAN ) Adoption Rule 9 IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the matter of the adoption of ) ) ) ) (child's name after adoption) ) ) DOB: , A Minor Child, ) ) By , ) CASE NO. Petitioner. ) ) ADOPTION CONSENT (PARENT/SPOUSE/GUARD IAN) 1. Name of individual signing consent to adoption: 2. Child’s name after adoption: 3. Relationship to child: 4. I understand that prior to signing this consent I have the right to consult with an attorney of my choice, at my expense. I also understand that if I do not sign the consent , but the person(s) seeking to adopt the child proceeds with filing the adoption petition anyway , I may be eligible to request a court -appointed attorney. 5. I consent to the adoption of the above -named child by the person( s) filing the adoption petition . 6. Legal Rights and Custody. I am married to the petitioner and I am retaining my rights to care, custody, and control of the child. I understand that by signing this consent, I am giving up all my rights to the care, custody and control of the child, and that I am giving up these rights permanently. I will also be permanentl y relieved of all responsibility for the child after the decree of adoption is signed. Except as stated in paragraph 7 below concerning inheritance and visitation privileges , I will no longer have any legal relationship to the child. 7. Visitation Privilege s. This section is not applicable to me because I am married to the petitioner so I am retaining my legal rights to care, custody, and control of the child. I do not want to keep any visitation privileges after the adoption is granted. I r equest that the court grant me my relative visitation privileges with the child at the discretion of the adoptive parent (s), according to the best interests of the child. Page 2 of 3 P-415 ( 8/17)(cs ) AS 25.23.060-.070 ADOPTION CONSENT (PARENT/SPOUSE/GUARDIAN) Adoption Rule 9 I request that the court grant me my relative the following visitation privileges with the child: (Describe visitation agreement, including times, places, who pays for transportation, etc. Attach any visitation agreement if applicable.) 8. The child is is not a member of an Indian tribe ; or eligible for such membership and I, or the other biological parent, am a member of an Indian tribe. 9. I understand I have a limited right to withdraw my consent. I understand that my consent cannot be withdrawn after the judge signs the decree of adoption. However, before the adoption decree is signed, I can withdraw my consent as follows: a.For a Non-Indian Child: Within 10 days after I sign this form, I can deliver written notice of withdrawal to the court at the address in paragraph 10 or to the person who obtained my consent. This written notice must be delivered or postmarked by the tenth day , and I must keep a copy of that notice of withdrawal and record the date it was delivered or postmarked. After the above 10-day period, if the adoption decree has not been signed, I can file a request to withdraw with the court, which the court may or may not grant. My request will be granted only if the court finds that it is in the best interests of the child after both the person seeking to adopt and I are given notice and an opportunity to be heard. b. For an Indian Child At any time before the signing of the decree of adoption, I can deliver written notice of withdrawal to the court at the address in paragraph 10 or to the person who obtained my consent. This written notice must be delivered or postmarked by the last day of this time period, and I must keep a copy of that notice and record the date it was delivered or postmarked. 10. I understand that the adoption petition will be filed in the Superior Court at: Court Address: Co urt Telephone Number: [ NOTE: You can find the location and court telephone number here: http://www.courts. alaska.gov/courtdir/index.htm ]11. I am am not a minor. My date of birth is . 12. I have received a copy of this consent (or will receive one after it is signed). 13. I do do not want to receive notice of the date and time of the adoption hearing. Page 3 of 3 P-415 ( 8/17 )(cs ) AS 25.23.060 -.070 ADOPTION CONSENT (PARENT /SPOUSE/GUARDIAN ) Adoption Rule 9 I state on oath or affirm that I have read this consent form and believe all statements made in it are true. I am sig ning this consent freely and voluntarily. Note: This consent must be signed in a hearing in the presence of a judge when the consenting person is the parent of an Indian child or the consenting person is a minor. Date Signature of Person Giving Consent Print Name Mailing Address City State Zip Daytime Phone ______________________________________ Email Address ACKNOWLEDGEMENT & OATH On , personally appeared (date) (name) before me in , Alaska, signed the above consent to adoption, certified under oath or affirmation that he/she has read it and believes its contents to be true, and acknowledged that he/she signed the consent freely and voluntarily for the purposes stated therein. (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: