CONSENT TO ADOPTION BY GUARDIAN OR AGENCY
(Non-Stepparent Adoption)
I swear or affirm under oath that the facts set forth below are true and I consent to the adoption of the minor
child named below.
Information about Guardian or Representative of Agency signing the Consent:
My Name: _________________________________________ Date of Birth: _____________________________
Address: __________________________________________ Email Address: ____________________________
City/State/Zip: _____________________________________ Daytime Phone: ___________________________
Name of Attorney: ____________________________________________________________________________
Address of Attorney: _________________________________ City/State/Zip: ____________________________
Information about the Minor to be Adopted:
Minor’s Name: ______________________________________ Date of Birth: _____________________________
Information about the Attorney Who Represents the Prospective Adoptive Parents:
Name of Attorney: __________________________________ Phone: __________________________________
Address: __________________________________________ City/State/Zip: ____________________________
I am: (Check One Box Only)
☐ the Guardian of this minor and my consent is required for his/her adoption.
☐ a duly authorized representative of an agency whose consent is required for the adoption of this
minor.
Information about the agency is as follows:
Name of Agency: _____________________________________ Phone: _____________________________
Address: ___________________________________________ City/State/Zip: _______________________
I,
or my agency, obtained the authority to consent to the adoption in the following manner: (Describe)
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