Free Specific Consent to Adoption - Hawaii

FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I

SPECIFIC CONSENT TO ADOPTION OF [ ]MOTHER [ ]FATHER [ ]OTHER

CASE NUMBER FC-A NO.

INFORMATION REGARDING THE PROPOSED ADOPTIVE PARENTS: PETITIONER Name (Full Legal Name)
Relationship to Child(ren)

PETITIONER

INFORMATION REGARDING THE CHILD(REN)'S PARENTS FATHER Name (Full Legal Name) Street Address City, State, Zip Code Telephone Number Social Security Number Date of Birth Racial Extraction INFORMATION REGARDING THE CHILD(REN)'S PARENTS LEGAL ONLY FATHER Name (Full Legal Name) Street Address City, State, Zip Code Telephone Number Social Security Number Date of Birth Racial Extraction OTHER LEGAL PARENT MOTHER

08/07/01

PAGE 1 OF 4 PAGES

SPECIFIC CONSENT TO ADOPTION

FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I

SPECIFIC CONSENT TO ADOPTION OF [ ]MOTHER [ ]FATHER [ ]OTHER

CASE NUMBER FC-A NO.

INFORMATION REGARDING THE CHILD Full Legal Name Sex Date of Birth Place of Birth [ ]MALE [ ]FEMALE

INFORMATION REGARDING THE CHILD Full Legal Name Sex Date of Birth Place of Birth [ ]MALE [ ]FEMALE

INFORMATION REGARDING THE CHILD Full Legal Name Sex Date of Birth Place of Birth [ ]MALE [ ]FEMALE

INFORMATION REGARDING THE CHILD Full Legal Name Sex Date of Birth Place of Birth
08/07/01 PAGE 2 OF 4 PAGES SPECIFIC CONSENT TO ADOPTION

[ ]MALE [ ]FEMALE

FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I

SPECIFIC CONSENT TO ADOPTION OF [ ]MOTHER [ ]FATHER [ ]OTHER

CASE NUMBER FC-A NO.

The undersigned being first duly sworn on oath, deposes and says that: 1. 2. I am the parent of the above-identified child(ren), I hereby consent to the legal adoption of said above-identified child(ren) by the above-named proposed adoptive parent(s), with the understanding and intent that when such adoption is completed by the entry of a decree, the legal name of the child(ren) may be changed: (Check only one (1) of the following) [] [] I understand that after I sign this Consent to Adoption and the Court approves the adoption all of the my parental rights as well as responsibilities for said child(ren) will continue. I understand that after I sign this Consent to Adoption and the Court approves the adoption all of the my parental rights as well as responsibilities for said child(ren) will be terminated. I further understand that by signing this Consent to Adoption I will give up any legal right that I may have to provide care, guidance and control for said child(ren). I further understand that by signing this Consent to Adoption I will give up any legal right that I may have to visit with said child(ren). I declare that no representations have been made to me, by anyone, which would serve in any way to limit the complete surrender of all the my parental rights intended by this consent or to limit the parental rights to be acquired by the proposed adoptive parent(s). 3. 4. I further understand that after this consent has been signed by me, the consent will be valid and binding, even though I may be under the age of 18 years. I further understand that after the child(ren) has started to reside with the adoptive parent(s) reflected on Page 1 of this Consent to Adoption or after this consent has been filed with the Court in an adoption proceeding by the proposed adoptive parent(s), this consent may not be withdrawn or repudiated without the written order of a judge who has jurisdiction in adoption proceedings, based upon a written finding, supported by proof to be submitted by me, that the withdrawal of my consent would be in the best interest of the child(ren). No one has forced or coerced me to sign this Consent to Adoption. No one has made any promises whatsoever to me in return for signing this Consent to Adoption. I have not been offered nor have I accepted any reward or money in exchange for signing this Consent to Adoption. I waive further notice of any proceeding regarding the adoption of the child(ren), however if the adoption fails to be granted, I want to be given notice.
PAGE 3 OF 4 PAGES SPECIFIC CONSENT TO ADOPTION

5. 6. 7. 8.
03/25/02

FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I

SPECIFIC CONSENT TO ADOPTION OF [ ]MOTHER [ ]FATHER [ ]OTHER

CASE NUMBER FC-A NO.

CONFIDENTIALITY PURSUANT TO HRS §578-15:
9. 10. 11. I have been advised of the requirements of Section 578-15 of the Hawai`i Revised Statutes regarding confidentiality of the court's adoption file. When my child becomes 18 years old, my child or the adoptive parents can request, in writing, to see the court's file regarding this adoption. If I do not want the Family Court to reveal my identity to my child or the adoptive parents, I must file an affidavit requesting confidentiality with the Family Court (on this island that the adoption occurred) within ninety (90) calendar days before my child's 18th birthday. This affidavit is good for ten (10) years. After that, I can file an affidavit every ten (10) years or I can file an affidavit to keep my identity confidential for the rest of my life. All affidavits must be filed within ninety (90) days prior to the expiration of the previous affidavit. After my child reaches 18 years old, I can request to see the court's adoption file, too, but my child has the same rights as I do the keep the file confidential. My decision to keep my information confidential or not applies to only me and does not apply to the other natural parent. I can agree to open up the adoption file at any time and my child can to after turning 18 years old. It will be my responsibility to keep the Family Court informed of my current address if I want disclosure to be made. The Family Court has no responsibility to notify the child, adoptive parent(s) or the natural parent(s) of any deadlines or expiration dates.

12. 13. 14. 15. 16. 17. 18.

DATE

SIGNATURE OF PARENT

On this day, before me personally appeared , to me known to be person named in and who executed the foregoing consent to adoption and acknowledged that said consent was read and is understood by said person and was executed as the free act and deed of said person. State of Hawai`i, County of Honolulu: Date
08/07/01 PAGE 4 OF 4 PAGES

Signature:

Printed Name of Notary Public:

Commission Expires:

Notary Public, State of Hawai`i
SPECIFIC CONSENT TO ADOPTION