Parent Consent Form

A. Petitioner(s) resides at the address stated on the Petition.

B. I (Respondent) reside at the address stated on the Petition.

C. The child(ren)’s name, date of birth, place of birth, and gender are correctly stated on the Petition.

D. The parents’ names and addresses are correctly stated on the Petition.

E. The name(s) and address(es) of the person(s) or organization having the guardianship, care, control or custody of the child(ren) are correctly stated on the Petition.

F. Adoption of the child(ren) is possible and appropriate.

G. If both parents’ parental rights are sought to be terminated in the Petition, the possibility of placement of the child(ren) with blood relatives has been explored.

H. Termination of my parental rights is in the best interests of the child(ren).

I. Pursuant to 13 Del. C. §§ 1103(a)(1) and 1106, I agree (consent) that this Petition be granted and I have provided a signed and notarized Consent to Termination and Transfer of Parental Rights form to the Petitioner for filing with the Court.

J. As defined under 13 Del. C. §§1101(1) and 1103(a)(2)(a), I have intentionally abandoned the child as evidenced by the fact that one of the following statements made in the Petition is true:

i. The child is younger than 6 months old at the time of filing the Petition and I failed to pay reasonable prenatal, natal and postnatal expenses in accordance with my financial means and I failed to visit regularly with the child and I failed to manifest (show) an ability and willingness to assume legal and physical custody of the child (if the child was NOT in the physical custody of the other parent).

ii. The child is at least 6 months old at the time of filing of the Petition and for at least 6 consecutive months (6 months in a row) during the year immediately before filing the Petition, I failed to make reasonable and consistent payments in accordance with my financial means for support of the child and I failed to communicate or visit regularly with the child and I failed to manifest (show) the ability and willingness to assume legal and physical custody of the child (if the child was NOT in the physical custody of the other parent).

iii. The child is younger than 6 months old at the time of filing the Petition and I have manifested (shown) the unwillingness to exercise my parental rights and responsibilities as evidenced by my placing the child in circumstances leaving the child in substantial risk of injury or death.

K. As defined under 13 Del. C. §§1101(1) and 1103(a)(2)(b), I have unintentionally abandoned the child(ren) because for 12 consecutive months (12 months in a row) in the 18 months before this Petition was filed, I failed to communicate or visit regularly with the child and I failed to file or pursue a pending Petition to establish paternity or to establish the right to have contact or visitation with the child and I failed to manifest (show) the ability and willingness to assume legal and physical custody of the child (if the child was NOT in the physical custody of the other parent) and at least 1 of the following circumstances applies:

The child is not in the legal and physical custody of the other parent and I am not able or willing promptly to assume legal and physical custody of the child, and to pay for the child’s support in accordance with my financial means;

OR The child is in the legal and physical custody of the other parent and stepparent, and the stepparent is the prospective adoptive parent, and I am not able or willing promptly to establish and maintain contact with the child and to pay for the child’s support in accordance with my financial means.

OR Placing the child in my legal and physical custody would pose a risk of substantial harm to the physical or psychological well being of the child because the circumstances of the child’s conception, my behavior during the mother’s pregnancy or since the child’s birth, or my behavior with respect to other children indicates that I am unfit to maintain a relationship of parent and child with the child.

OR Failure to terminate my parental rights over the child would be detrimental to the minor.

L. I am mentally incompetent and therefore unable to discharge parental responsibilities in the foreseeable future.

M. I have been found by a court of competent jurisdiction to have committed a felony level offense found within 11 Del. C. §§ 601-792 against a victim who was a child, or to have aided or abetted, attempted, conspired or solicited to commit such offense found within 11 Del. C. §§ 601-792, or to have committed or attempted to commit the offense of Dealing in Children found at 11 Del. C. § 1100, or to have committed the felony level offense of Endangering the Welfare of a Child found at 11 Del. C. § 1102.

N. I am not able or have failed to plan adequately for the child’s physical needs or mental and emotional health and development and 1 or more of the following conditions are met:

i. In the case of a child in the care of the Department of Services for Children, Youth and Their Families (“the Department”), the child has been in the care of the Department or licensed agency for a period of 1 year (or for a period of 6 months in the case of a child who comes into care as an infant) or there is a history of previous placement(s) of this child, or there is a history of neglect, abuse, or lack of care of the child or other children by me, or I am incapable of discharging parental responsibilities due to extended or repeated incarceration, or I am not able or willing to assume promptly legal and physical custody of the child and to pay for the child’s support in accordance with my financial means, or failure to terminate my parental rights over this child will result in continued emotional instability.

ii. In the case of a child in the home of a stepparent or blood relative, the child has resided in the home of the stepparent or blood relative for a period of at least 1 year (or for a period of 6 months in the case of an infant) and I am incapable of discharging parental responsibilities and there is little likelihood that I will be able to discharge such parental responsibilities in the future.

O. My parental rights over a sibling (i.e. brother or sister or half-brother or half-sister) of the child have been involuntarily terminated in a prior proceeding.

P. I have subjected the child to torture, chronic abuse, sexual abuse, and/or life-threatening abuse.

Q. The child has suffered unexplained serious physical injury under such circumstances as would indicate that such injuries resulted from my intentional conduct or my willful neglect.