Fill - Free fillable CIRCUIT COURT FOR , MARYLAND CONSENT OF PARENT (Maryland Courts) PDF form

CIRCUIT COURT FOR

City or County

, MARYLAND

Located at

Case No.

Court Address

vs.

Petitioner Respondent

CONSENT OF PARENT TO AN INDEPENDENT ADOPTION WITHOUT

TERMINATION OF PARENTAL RIGHTS (FORM 9-102.5)

CONSENT OF PARENT TO ADOPTION OF

Independent Adoption without Termination of Parental Rights

INSTRUCTIONS

These instructions and attached consent form may be used only in independent adoptions, not

those that are arranged by an adoption agency. This form should only be used for a parent whose

parental rights are not being terminated. It should be used for a parent who is retaining parental

rights, for example, a custodial parent in a step-parent adoption. Code, Family Law Article, Title

5, Subtitle 3B.

The attached consent form is an important legal document. You must read all of these

instructions BEFORE you sign the consent form. If you do not understand the instructions

or the consent form, you should not sign it. If you are under 18 years old or if you have a

disability that makes it difficult for you to understand, do not sign the consent form unless

you have a lawyer.

A. Right to Have This Information in a Language You Understand

You have the right to have these instructions and the consent form translated into a language that

you understand. If you cannot read or understand English, you should not sign the consent form.

You should have this form translated for you into a language you do understand. The translated

consent form is the one you should read and decide whether or not to sign. Any translation must

have an affidavit attached in which the translator states that it is a true and accurate translation of

this document.

B. Right to Speak With a Lawyer

You have the right to speak with a lawyer before you decide whether or not to consent.

You should not sign the consent form without a lawyer if you are under 18 years old or have a

disability that makes it difficult for you to understand this document. If you are under 18 years

old or have a disability that makes it difficult for you to understand this document, you are

required to have a lawyer review the form with you before you can consent to the adoption.

Even if you are not required to have a lawyer, you have the right to speak with a lawyer you

choose before you decide whether to consent.

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C. Right to Adoption Counseling

You have the right to receive adoption counseling and guidance. If you want adoption counseling

or guidance, you should not complete this consent form until after you have gotten adoption

counseling or guidance.

D. Effect of Signing the Consent Form

IF YOU SIGN THE CONSENT FORM, YOU WILL NOT BE GIVING UP ANY RIGHTS

OR RESPONSIBILITIES RELATING TO THE CHILD.

E. Right to Revoke Consent

If you sign the consent form and then change your mind and no longer want to consent, you have

the right to revoke (cancel) the consent within 30 days after the date that you sign the consent

form. The only way that you can revoke this consent is by giving a signed written revocation

statement with the name, sex, and date of birth of the child (if you know it) to:

Adoption Clerk, Circuit Court for at (Address).

The revocation must be sent to the court, not to the lawyers or the people adopting the child. You

may deliver your written revocation of consent in person or by mail. If it is not received by the

Adoption Clerk's office within 30 days after the date you signed the consent form, it will be too

late, and you will not be able to withdraw the consent or stop the adoption from being granted.

If you sign this consent form, and then revoke your consent, and then decide to consent to the

adoption again, you will not be able to revoke your second consent if you give your second

consent in court within one year of your revocation of this consent.

G. Further Notice of Adoption Proceedings

A petition for adoption has been or will be filed in the Circuit Court for .

If you sign the consent form, your written consent will also be filed in the court. You have the

right to be notified when the petition is filed, when any hearings are held before the adoption is

granted, and if and when the adoption is granted. Any notices will be sent to the address given by

you on the consent form, unless you write to the Adoption Clerk at

(court's address) and give the clerk your new address. You may

waive (give up) your right to notice if you wish to do so. Even if you give up your right to notice,

someone from the court may contact you if further information is needed.

H. Compensation

Under Maryland law, you are not allowed to charge or receive money or compensation of any

kind for the placement for adoption of your child or for your agreement to the adoptive parent

having custody of your child, except for (1) reasonable and customary charges or fees for

adoption counseling, hospital, legal, or medical services, (2) reasonable expenses for

transportation for medical care associated with the pregnancy or birth of the child, (3) reasonable

expenses for food, clothing, and shelter for a birth mother if, on written advice of a physician, the

birth mother is unable to work or otherwise support herself because of medical reasons associated

with the pregnancy or birth of the child, and (4) reasonable expenses associated with any required

court appearance relating to the adoption, including transportation, food, and lodging expenses.

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I. Access to Birth and Adoption Records

When your child is at least 21 years old, your child, your child's other parent, or you may apply

to the Secretary of the Maryland Department of Health for access to certain birth and adoption

records. If you do not want information about you to be disclosed (given) to that person, you

have the right to prevent disclosure by filing a disclosure veto. Attached to this document is a

copy of the form that you may use if you want to file a disclosure veto.

J. Adoption Search, Contact, and Reunion Services

When your child is at least 21 years old, your child, your child's other parent or siblings, or you

may apply to the Director of the Social Services Administration of the Maryland Department of

Human Services for adoption search, contact, and reunion services.

K. Rights Under the Indian Child Welfare Act

If you or your child are members of or are eligible for membership in an Indian tribe, as defined

by federal law, you have special legal rights under the Indian Child Welfare Act. You should not

sign this consent form if you believe this may apply to you. You should tell the person requesting

the consent or the court that you believe that your child's case should be handled under the

Indian Child Welfare Act.

L. Signature, Witness, and Copy

If you decide to complete and sign the consent form, you must have a witness present when you

sign it. The witness must be someone 18 or older and should not be the child or the child's other

parent. You must complete and sign the form with a pen and print or type in your name, address,

and telephone number. The witness also must sign the form and print or type in the witness'

name, address, and telephone number in the blanks on the last page.

If you have a post-adoption agreement, you must attach a copy to the signed consent form.

You have the right to receive a copy of the signed consent form.

STOP HERE IF YOU DID NOT UNDERSTAND SOMETHING YOU HAVE READ OR

IF YOU WANT TO SPEAK WITH A LAWYER OR GET ADOPTION COUNSELING

BEFORE YOU DECIDE IF YOU WANT TO SIGN THE CONSENT FORM.

If you wish to sign the consent form, you must also sign here to verify that you read these

instructions and understand them:

(Signature)

(Date)

You must attach a copy of these signed instructions to the signed consent form.

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CONSENT TO INDEPENDENT ADOPTION

WITHOUT TERMINATION OF PARENTAL RIGHTS

Use a pen to fill out this form. You must complete each section.

A. Identifying Information

1. Language.

I understand English, or this consent form has been translated into , a language

that I understand.

2. Name.

My name is

3. Age.

My date of birth is

4. Child.

The child who is the subject of this consent was born on (date) at

(name of hospital or address of birthplace), in

(city, state, and county of birth).

5. Status as Parent. Check all that apply.

(a) I am

the mother of the child the father of the child alleged to be the father of the child

(b) I was married to the mother of the child

at the time of conception of the child at the time the child was born.

B. Right to Speak with a Lawyer

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

I already have spoken with a lawyer whose name and telephone number are

. I have read the instructions at the front of this

form, and I am ready to consent to the adoption.

I am at least 18 years old and am able to understand this document. I have read the

instructions at the front of this form, and I do not want to speak with a lawyer before I

consent to the adoption.

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C. Right to Counseling and Guidance

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

I have already spoken with a counselor. I have read the instructions at the front of this

form, and I am ready to consent to the adoption.

I do not want to speak with a counselor. I have read the instructions at the front of this

form, and I am ready to consent to the adoption.

D. Consent

I voluntarily and of my own free will consent to the adoption of my child,

, by

E. Notice

Check one of the following:

I give up (waive) the right to any further notice of the adoption case.

I want to be notified when the adoption case is filed, of any hearings, and if and when my

child is adopted.

F. Revocation Rights

I understand that if I change my mind and no longer consent to the adoption, I have the right to

revoke this consent within 30 days after the date that I signed this consent form. I understand

that the only way that I can revoke this consent is by giving a signed written revocation statement

to the Adoption Clerk, Circuit Court for at

G. Effect of this Consent

I UNDERSTAND THAT IF I SIGN THIS CONSENT FORM, I WILL NOT BE GIVING

UP ANY RIGHTS AND RESPONSIBILITIES RELATING TO THE CHILD.

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H. Oath and Signature

I have read carefully and understand the instructions at the front of this consent form. I am signing

this consent form voluntarily and of my own free will.

I solemnly affirm under the penalties of perjury that the contents of this consent form are true to

the best of my knowledge, information, and belief.

(Date)

(Signature)

(Printed Name)

(Address)

(City, State, Zip Code)

(Telephone Number)

Witness:

(Signature)

(Date)

(Printed Name)

(Address)

(City, State, Zip Code)

(Telephone Number)

A COPY OF THE INSTRUCTIONS WITH YOUR SIGNATURE MUST BE ATTACHED

TO THIS CONSENT.

CC-DR-102 (10/2017)

Page 6 of 6

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