Free CCCO 0004 10-05-07.pmd - Illinois

Consent of a Person Aged Fourteen or Older

(This form replaces CCO-12)

(Rev. 10/05/07) CCCO 0004

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF

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and

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TO ADOPT:

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No. ___________________________

CONSENT OF A PERSON AGED FOURTEEN OR OLDER (2721)
I, _____________________________________________________, state: 1. I reside at _____________________________________________________________________________, County of _______________________________, and State of _____________________________. 2. My age is ___________ years. 3. I consent and agree to my adoption by _____________________________________________________ and _____________________________________________________________________________________________. 4. I further consent and agree to the change of my name to __________________________________________ __________________________________________________________________________________________________________. 5. I hereby waive service of summons and enter my appearance in these proceedings. Dated: _________________________________, ________ ________________________________________________ (Signature of minor)

I, _________________________________________________, a Judge of the Circuit Court of Cook County, Illinois, do hereby certify that ______________________________________________________________, personally known to me to be the same person whose name is signed on the foregoing consent, and that s/he appeared before this day in person and acknowledged that s/he signed and delivered this consent as his/her free and voluntary act, for the purpose specified in it. In witness whereof, I have affixed my signature to this document on this _______________ day of

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Judge (COURT SEAL) Judge's No.

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS