Annex B to the Special Commission Report of October 1994
RECOMMENDED MODEL FORM
STATEMENT OF CONSENT TO THE ADOPTION
Hague Convention of 29 May 1993
on Protection of Children and Co-operation in Respect of Intercountry Adoption
I STATEMENT OF CONSENT
Read the following statements carefully before completing them. Sign below only when you fully understand each statement. You have the right to receive any counselling or information which you may want to have about the effects of your consent. You have the right, if you so desire, to receive a copy of this document.
You should not have received any payment or compensation of any kind made or offered for the purpose of obtaining your consent to the adoption of the child.
I, the undersigned:
Family name: .....................................................
First name(s): ...................................................
Date of birth: day .... month .... year ...
Habitual residence: ..............................................
mother [] father [] legal representative [] of the child:
Family name: .....................................................
First name(s): ...................................................
Sex: male [] female []
Date of birth: day .... month .... year ....
Place of birth: ..................................................
Habitual residence: ..............................................
declare as follows:
1 - I freely consent, without threat or coercion, to the adoption of this child.
2 - I understand that my child may be adopted by spouses or a person residing abroad.
3 - I understand that the adoption of this child will create a permanent parent-child relationship with the adoptive parent(s).
4 - I give my consent for the purpose of an adoption that terminates the pre-existing legal parent-child relationship between the child and his or her mother and father.
5 - I have been informed that I may withdraw my consent until ............. and that after that date my consent will be irrevocable.
I declare that I have fully understood the above statements.
Done at ................ on ..............
Signature or Mark:
II DECLARATION OF WITNESS(ES) (where required by law or by the circumstances, e.g. in the case of illiterate or handicapped persons)
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III CERTIFICATION OF THE AUTHORITY AUTHORIZED TO ATTEST THE CONSENT
Name: ........................................................
Title: .......................................................
I hereby certify that the person (and the witness(es)) named or identified above appeared before me this date and signed this document in my presence.
Done at ................ on ..............
Signature / Seal: