Fillable CONS Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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CONS Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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© 2017 Family Law Self-Help Center Consent to Adoption (parent)
* You are responsible for knowing the law about your case. For more information on the law, this form, and free classes,
visit www.familylawselfhelpcenter.org or the Family Law Self Help Center at 601 N. Pecos Road. To find an attorney,
call the State Bar of Nevada at (702) 382-0504.
1
CONS
Name: ______________________________
Address: ____________________________
City, State, Zip: _______________________
Phone: ______________________________
Email: ______________________________
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Petition of
_
_____________________________ and
_
_____________________________
(adoptive parents’ names)
For adoption of a minor child.
CASE NO.: ____________________
DEPT: ____________________
CONSENT TO TERMINATION OF PARENTAL RIGHTS AND ADOPTION
1. I, (consenting parent’s name) __________________________________________, am
the natural ( check one) mother / father of the following children:
Child’s Full Name: Date of Birth Male /
Female
2. I give my unqualified and absolute consent to the termination of my parental rights as to
my minor children named above.
THIS FORM MUST BE SIGNED IN FRONT OF TWO NEUTRAL WITNESSES AND A NOTARY.
Once you complete the form, print it out and sign it in front of two witnesses and a notary. The parent's original
signature, the witnesses' signatures, and the notary's stamp and signature must appear on the document that
is filed with the court.
Page 2 of 4 – Consent to Adoption (parent)
3. I give my full and free consent to the adoption of the above named children to (name of
first petitioner) _________________________________________ and (name of second
petitioner or “n/a”) ______________________________________.
4. The best interests of the children will be served by the termination of my rights and the
adoption by the petitioners named above.
I understand that this consent cannot be revoked or nullified. I waive notice of any further
proceedings based on my consent to the adoption.
DATED this (day) ______ day of (month) ______________, 20____.
Submitted By: (parent’s signature) _____________________________
(print your name) ________________________________
VERIFICATION
STATE OF ___________________ )
)
COUNTY OF _________________ )
(Parent’s Name) ________________________________________ being first duly sworn
under penalty of perjury, deposes and says:
I am the person named herein, and I have read the foregoing CONSENT TO
TERMINATION OF PARENTAL RIGHTS AND ADOPTION and know the contents
thereof; that the pleading is true to the best of my own knowledge, except as to those matters
therein stated upon information and belief, and as to those matters, I believe them to be true.
(signature) ____________________________________
Signed and sworn to (or affirmed) before me on
(date) _____________ by (name) ____________________
Signature of notarial officer
Page 3 of 4 – Consent to Adoption (parent)
ACKNOWLEGMENT
STATE OF ___________________ )
)
COUNTY OF _________________ )
On this _________ day of _______________________ 20____, personally appeared
before me, a Notary Public, (parent’s name) _________________________________________,
known or proved to me to be the person who executed the foregoing CONSENT TO
TERMINATION OF PARENTAL RIGHTS AND ADOPTION, and who acknowledged to
me that he/she did so freely and voluntarily and for the uses and purposes herein stated.
Signature of notarial officer
Page 4 of 4 – Consent to Adoption (parent)
AFFIDAVIT OF WITNESSES
STATE OF NEVADA )
)
COUNTY OF CLARK )
On this (day) _______ day of (month) ___________________, 20_____, then and there
personally appeared the within named (first witness) __________________________________
and (second witness) ___________________________________, who, being duly sworn,
depose and say: That they witnessed the execution of the within consent to adoption by (name of
consenting parent) __________________________________; that she, he or they subscribed the
consent to adoption and declared the same to be a voluntary consent to adoption in their
presence; that at the time the consent to adoption was executed it contained the names of the
person or persons to whom consent was thereby given to adopt the child; that they thereafter
subscribed the same as witnesses in the presence of (name of consenting parent)
__________________________________ and in the presence of each other and at the request of
(name of consenting parent) __________________________________; that at the time of the
execution of the consent to adoption (name of consenting parent)
__________________________________ acknowledged to them that she, he or they was or
were, and she, he or they appeared to them to be, in full possession of her, his or their faculties
and not under the influence of any drug or sedative or subject to any duress, fear, menace,
compulsion or undue influence whatever; and that they make this affidavit at her, his or their
request.
________________________________
(First Witness’s signature)
________________________________
(First Witness’s printed name)
________________________________
(Second Witness’s signature)
_________________________________
(Second Witness’s printed name)
SUBSCRIBED and SWORN to before
me this ______ day of
(month) ___________, (year) ________.
_________________________________
NOTARY PUBLIC
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CONS Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Family Law Self Help Center)

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Completed 9 February 2021

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