Free CCCO 0005 9-19-07.pmd - Illinois

Final and Irrevocable Consent to Adoption

(This form replaces CCO-11)

(Rev. 9/19/07) CCCO 0005

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. ___________________________________

FINAL AND IRREVOCABLE CONSENT TO ADOPTION (2723 FATHER 2724 MOTHER)
I, _______________________________________________________________________, (mother/father) of

_________________________________________________________________________ a female/male child, state:
1. The child was born on _____________________________, _________ at ___________________________, State of ____________________________________. 2. I reside at ________________________________________________________________________________,

County of _________________________________, and State of __________________________________. 3. 4. 5. My age is ___________ years. I hereby enter my appearance in this proceeding and waive service of summons on me. I do hereby consent and agree to the adoption of such child.

6. I wish to, and understand that by signing this consent I do, irrevocably and permanently give up all custody and other parental rights I have to the child named above. 7. I understand the child will be placed for adoption and that I cannot under any circumstances, after signing this document, change my mind and revoke or cancel this consent or obtain or recover custody or any other rights over the child. I have read and understand the above and I am signing it as my free and voluntary act. Dated this ___________ day of ______________________, _______

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(Signature of Parent)

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 specified purpose. In witness whereof, I have affixed my signature on this document on this _______________ day of

__________________________________, __________
Atty. No. _________________ Name: ___________________________________________ Address: _________________________________________ City/State/Zip: _____________________________________ Telephone: ________________________________________

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Judge Judge's No.

(Court Seal)

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