PROBATE COURT OF WAYNE COUNTY, OHIO
ADOPTION OF:
(Name after adoption)
CASE NO.
CONSENT TO ADOPTION
[R.C. 3107.06, 3107.08 & 3107.081]
The undersigned
[Check one of the following seven capacities by which your consent is given]
Mother
Father
Putative father who has registered under R.C. 3107.062 (for minor born on or after January
1997)
Putative father (for a minor born before January 1, 1997)
Agency having permanent custody
Minor, who is more than twelve years of age (this consent must be executed in the presence
of the Court)
Other
herby waives notice of the hearing on the Petition For Adoption to be filed in the court, and consents
to the adoption of
(Name before adoption)
as proposed in the petition.
The undersigned further states that this consent is voluntarily executed irrespective of disclosure of the
name or other identification of the prospective adopting parents.
Sworn to before me and signed in my presence this
day of
, 20
.
Person authorized pursuant to R.C. Chapter 3107
To take this acknowledgement
Title
WC Probate Form 18.3