Free STATE OF MINNESOTA - Minnesota

State of Minnesota
County Judicial District: Court File Number: Case Type:

District Court
Adoption ­ Stepparent

In the Matter of the Petition of: , Petitioner/Parent and , Petitioner/Stepparent To Adopt: , (child's current name) , (child's current name) , (child's current name) I, oath, depose and state as follows: 1. I was born on and I reside at in the City of State of
[child's name] , [date of birth] ,

CONSENT TO ADOPTION BY CHILD AGE 14 OR OLDER

being first duly sworn upon years of age,
[street address] ,

I am currently

, County of .

,

2. Of my own free will, and in the presence of two competent witnesses, I hereby consent to being adopted by the Petitioner [stepparent's name] . Child's Signature Dated:
[Signature of child ­ sign only in front of notary public and two witnesses]

Witnesses' Signatures Dated:
[Witness ­ sign only in front of notary public]

Dated:
[Witness ­ sign only in front of notary public] On this day of , , before me personally appeared the person described herein who executed the foregoing consent and acknowledged that such consent was freely given, and the persons who were present when such consent was executed. Notary Public

AD0204

State

ENG

Rev 5/08

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