In the Circuit Court of the Seventeenth Judicial Circuit

IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT,

IN AND FOR BROWARD COUNTY, FLORIDA

Case No.:

Family Division

IN THE MATTER OF THE

TERMINATION OF PARENTAL

RIGHTS FOR THE PROPOSED

ADOPTION OF A MINOR CHILD.

______/

CONSENT TO ADOPTION

YOU HAVE THE RIGHT TO SELECT AT LEAST ONE PERSON WHO DOES NOT HAVE AN EMPLOYMENT, PROFESSIONAL, OR PERSONAL RELATIONSHIP WITH THE ADOPTION ENTITY OR THE PROSPECTIVE ADOPTIVE PARENTS TO BE PRESENT WHEN THIS AFFIDAVIT IS EXECUTED AND TO SIGN IT AS A WITNESS. YOU MUST ACKNOWLEDGE ON THIS FORM THAT YOU WERE NOTIFIED OF THIS RIGHT AND YOU MUST INDICATE THE WITNESS OR WITNESSES YOU SELECTED, IF ANY.

YOU DO NOT HAVE TO SIGN THIS CONSENT FORM. YOU MAY DO ANY OF THE FOLLOWING INSTEAD OF SIGNING THIS CONSENT OR BEFORE SIGNING THIS CONSENT:

1. CONSULT WITH AN ATTORNEY;

2. HOLD, CARE FOR, AND FEED THE CHILD UNLESS OTHERWISE

LEGALLY PROHIBITED;

3. PLACE THE CHILD IN FOSTER CARE OR WITH ANY FRIEND OR

FAMILY MEMBER YOU CHOOSE WHO IS WILLING TO CARE FOR

THE CHILD;

4. TAKE THE CHILD HOME UNLESS OTHERWISE LEGALLY

PROHIBITED; AND

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5. FIND OUT ABOUT THE COMMUNITY RESOURCES THAT ARE

AVAILABLE TO YOU IF YOU DO NOT GO THROUGH WITH THE

ADOPTION.

IF YOU DO SIGN THIS CONSENT, YOU ARE GIVING UP ALL RIGHTS TO YOUR CHILD. YOUR CONSENT IS VALID, BINDING, AND IRREVOCABLE

EXCEPT UNDER SPECIFIC LEGAL CIRCUMSTANCES. IF YOU ARE GIVING UP YOUR RIGHTS TO A NEWBORN CHILD WHO IS TO BE IMMEDIATELY PLACED FOR ADOPTION UPON THE CHILD'S RELEASE FROM A LICENSED HOSPITAL OR BIRTH CENTER FOLLOWING BIRTH, A WAITING PERIOD WILL BE IMPOSED UPON THE BIRTH MOTHER BEFORE SHE MAY SIGN THE CONSENT FOR ADOPTION. A BIRTH MOTHER MUST WAIT 48 HOURS FROM THE TIME OF BIRTH, OR UNTIL THE DAY THE BIRTH MOTHER HAS BEEN NOTIFIED IN WRITING, EITHER ON HER PATIENT CHART OR IN RELEASE PAPERS, THAT SHE IS FIT TO BE RELEASED FROM A LICENSED HOSPITAL OR BIRTH CENTER, WHICHEVER IS SOONER, BEFORE THE CONSENT FOR ADOPTION MAY BE EXECUTED. ANY MAN MAY EXECUTE A CONSENT AT ANY TIME AFTER THE BIRTH OF THE CHILD. ONCE YOU HAVE SIGNED CONSENT, IT IS VALID, BINDING, AND IRREVOCABLE AND CANNOT BE WITHDRAWN UNLESS A COURT FINDS THAT IT WAS OBTAINED BY FRAUD OR DURESS.

IF YOU BELIEVE THAT YOUR CONSENT WAS OBTAINED BY FRAUD OR DURESS AND YOU WISH TO INVALIDATE THAT CONSENT, YOU MUST:

1. NOTIFY THE ADOPTION ENTITY, BY WRITING A LETTER, THAT

YOU WISH TO WITHDRAW YOUR CONSENT; AND

2. PROVE IN COURT THAT THE CONSENT WAS OBTAINED BY

FRAUD OR DURESS.

AFFIDAVIT

I, ______, am the biological mother of the minor child subject to this consent, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

The name of the adoption entity for this adoptive placement is Adoption STAR, Inc., 1040 Bayview Drive, Suite 318, ______, Florida 33304. Telephone number (954) 566-6055.

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I understand that I have the right to choose a person who does not have an employment, professional, or personal relationship with the adoption entity or the prospective adoptive parents to be present when this consent is executed and to sign it as a witness. The witness I have selected is: ______.

I understand that, in signing this consent, I am permanently and forever giving up all of my parental rights to and interest in the minor child that is the subject of these proceedings. I understand that my consent is valid, binding and irrevocable and, upon execution, legal custody of the minor child is placed with the adoption entity for subsequent placement with the prospective adoptive parent or parents. I understand that there is not a "grace period" in Florida during which I may revoke my consent and further understand that this consent may thereafter only be withdrawn if the Court finds it was obtained by fraud or duress. I understand that pursuant to Chapter 63, Florida Statutes, "an action or proceedings of any kind to vacate, set aside, or otherwise nullify a judgment of adoption or an underlying judgment terminating parental rights on any ground may not be filed more than one (1) year after the entry of the judgment terminating parental rights."

I understand that I do not have to sign this consent nor release my parental rights to this child.

In signing this consent, I hereby acknowledge that the name or names of the adoptive parent(s) are not required for my granting of this consent. I further acknowledge that this consent is being given knowingly, freely, and voluntarily and is not given under fraud or duress. No one has forced, coerced, nor intimidated me in any way to sign this consent. I am of sound mind, understand the nature and consequences of these proceedings, and am not under the influence of any medication or substance, nor do I have a medical condition, which would alter my mind, mood or effect my judgment. I further acknowledge that any representation, express or implied, not included in writing in this consent is not binding on the parties.

I hereby waive any further notice of any and all proceedings to terminate my parental rights and for the subsequent adoption of said child.

Having the above stated knowledge and understanding of my legal rights, I hereby voluntarily consent, and of my own free will, release and permanently relinquish all rights to and custody of this minor child to Adoption STAR, Inc., as adoption entity, with full knowledge of the legal effect of the adoption and consent to the adoption of said child by person or persons whose name or names may be unknown to me.

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I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this Consent to Adoption and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

Dated: ______

BIRTH MOTHER

______

Signature of Witness Signature of Witness

Print Name: ______Print Name: ______

Address: ______Address: ______

______

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ at ______AM/PM by ______.

______

Notary Public

______Personally known

______Produced identification

Type of identification produced ______

ACKNOWLEDGMENT OF RECEIPT OF COPY OF CONSENT FOR ADOPTION

I hereby acknowledge that I was provided with a duplicate original of this Consent for Adoption on ______, 20___.

______

BIRTH MOTHER

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BIRTH PARENT’S CONSENT TO

ADOPTION ENTITY FILING PETITION FOR

TERMINATION OF PARENTAL RIGHTS

AND

WAIVER OF NOTICE AND APPEARANCE

I, ______, am the birth mother of the minor child subject to this consent and waiver, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

I consent to Adoption STAR, Inc. filing the petition to terminate my parental rights.

I waive further notice of any and all proceedings pertaining to the termination my parental rights and subsequent adoption of the minor child who is subject to this consent and waiver.

______

BIRTH MOTHER

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ by ______.

______

Notary Public

______Personally known

______Produced identification

Type of identification produced ______

WAIVER OF VENUE

I, ______, am the birth mother of the minor child subject to this waiver, who is a male child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

I consent to Adoption STAR, Inc. filing the petition to terminate my parental rights in Broward County, Florida.

I waive the right to hereafter request the court to transfer the petition to terminate my parental rights to a different county.

______

BIRTH MOTHER

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ by ______.

______

Notary Public

______Personally known

______Produced identification

Type of identification produced ______

IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT,

IN AND FOR BROWARD COUNTY, FLORIDA

Case No.:

Family Division

IN THE MATTER OF THE

TERMINATION OF PARENTAL

RIGHTS FOR THE PROPOSED

ADOPTION OF A MINOR CHILD.

______/

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT AFFIDAVIT

I, ______, being sworn, certify that the following statements are true:

1. I am the birth mother and custodian of the minor child subject to this affidavit, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

2. The minor child is known as ______and has not been issued a social security number.

3. Since birth, the minor child subject to this proceeding has resided at ______.

4. The minor child subject to this proceeding has never resided with a grandparent.

5. I have not participated as a party, witness, or in any capacity in any other litigation or custody proceedings in this or any other state, concerning custody of the minor child subject to this proceeding.

6. I have no information of any custody proceedings pending in a court of this or any other state concerning the minor child subject to this proceeding.

7. I do not know of any person not a party to this proceeding who has physical custody or claims to have custody or visitation rights with respect to the minor child subject to this proceeding.

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8. The minor child described in this affidavit is not subject to existing child support order(s) in this or any state or territory.

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

______

BIRTH MOTHER

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ by ______.

. ______

Notary Public

______Personally known

______Produced identification

Type of identification produced ______

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INDIAN CHILD WELFARE ACT AFFIDAVIT

I, ______, being sworn, certify that the following statements are true:

1. I am the birth mother of the minor child subject to this affidavit, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

2. My percentage of American Indian blood is ______.

3. I am not currently nor have I ever been a member of or registered with any American Indian tribe.

4. None of my family members are currently or ever have been members of or registered with any American Indian tribe.

5. Upon information and belief the minor child subject to this proceeding is not an Indian child. The Indian Child Welfare Act does not apply to this proceeding.

______

BIRTH MOTHER

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ by ______, who has produced ______as identification.

. ______

Notary Public

AFFIDAVIT OF REQUIRED INQUIRY

I, ______, have personal knowledge of the facts stated in this affidavit and certify that the following statements are true:

1. I am the birth mother of the minor child subject to this affidavit, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

2. Pursuant to Fla. Stat. 63.088(4):

a. At the time when conception of said minor child occurred and at the time of the birth of said minor child, I was married to ______.

b. As of this date, an affidavit of paternity pursuant to Fla. Stat. 82.013(2)(c)

has not been filed by any man.

c. The minor child has not been adopted by any man.

d. As of this date no man has been adjudicated by a court as the father of the minor child.

e. The biological father of the minor child is ______.

f. There is no other person other than ______who could be the biological father of the minor child who is the subject of this affidavit.

I understand that I am swearing or affirming under oath to the truthfulness

of the claims made in the affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

______

BIRTH MOTHER

STATE OF FLORIDA

COUNTY OF ______

Sworn to or affirmed and signed before me on this _____ day of ______, 20___ by ______, who produced ______as identification.

______

Notary Public

COUNSELING SUMMARY

I, ______, have personal knowledge of the facts stated in this Counseling Summary and certify that the following statements are true:

1. I am the birth mother of the minor child subject to this affidavit, who is a ______child born on the ______day of ______, 20___ at ______, ______, ______County, Florida.

2. I completed a Birth Parent Interview on ______, 20___ with a Social Worker employed by Adoption STAR, Inc. During the interview, we discussed my reasons for choosing adoption for my child and discussed options other than adoption that are available to me and my child.