Acknowledgment Of Natural Parent {19.6}

IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT PROBATE DIVISION ADOPTION ___________________________________________________________ (Name before Adoption) CASE NO. ______________________ ACKNOWLEDGMENT OF NATURAL PARENT (Mother) I, ____________________________, reside at ________________________________ ___________________ and my date of birth is ____________. I have had the following paragraphs fully explained to me and acknowledge that I understand my rights under the laws of the State of Ohio as set forth below. I further acknowledge that my signature below is placed voluntarily, without the undue influence of any person and without duress. I further state that I am not under the influence of any drugs or any alcohol which would impair my mental state. 1. The placement for purposes of adoption of an infant born to me on ____________ [date], is done by me without the involvement of any person, institution or agency certified by the Department of Job and Family as provided under Section 5103.03. If I am appearing unrepresented, I understand that _____________________, Esq. represents only the prospective adoptive family in this matter. 2. Ohio Revised Code Section 5103.16 has been fully explained to me. I understand that I am appearing before this Court today to request the approval of the placement, for purposes of adoption, of _______________________, which placement, if approved will occur today. I understand that the following must occur prior to the placement. a. I must personally apply to, and appear before this Probate Court, request the Court's approval of placement, and sign a written statement acknowledging my knowledge of my rights to contest the adoption under Section 3107.16. b. This Probate Court has ordered and received a report of an independent investigation of the proposed placement and determined that the placement is in the best interests of the child. c. This Probate Court must then approve the placement by entry entered into the record. 3. I understand that my request for approval of placement of my child with the prospective adoptive parents must be executed before a Judge of the Probate Court, or an authorized deputy or Referee (Magistrate) of the Court. 4. I understand that pursuant to Section 3107.16, the prospective adoptive parents require my consent to adopt this child. The consent which I execute as part of these proceedings is executed more than 72 hours after the birth of the child and is valid even American LegalNet, Inc. www.FormsWorkFlow.com if I do not know the name or identity of the proposed adoptive parents. If the child I am placing for adoption is more than six months old, I understand I must appear personally before the Court to sign my consent. Except as set forth herein, my consent is valid whether executed within or without the confines of the Court, and, if I am a minor, is binding as though I were an adult. 5. I understand that, prior to signing a consent to adoption, I must sign the component of the forms prescribed under (A)(I)(a)(b) and (c) of Section 3107.083 of the Revised Code. I have met with a qualified assessor to complete these forms. These forms were completed not less than seventy-two hours prior to the date I executed my consent to adoption. 6. Except as provided in 3107.051(B), I understand that a petition for adoption must be filed on behalf of the proposed adoptive parents no later than ninety (90) days after the date my child is placed in their home by the court. However, failure to file within this time does not affect a court's jurisdiction to hear the petition and is not grounds for denying the petition. 7. The hearing on the petition for adoption may be scheduled for an interlocutory hearing no sooner than thirty days after placement of the child in the proposed adoptive parents' home. After that hearing, if the Court grants an Interlocutory Order of Adoption, I cannot withdraw my consent to adoption. If no interlocutory hearing is held, this court will schedule a final hearing on the adoption no sooner than six months after placement. Should I request the withdrawal of my consent before the Interlocutory Order is granted, or, if no Interlocutory Order is granted then before a Final Decree of Adoption is granted, (in other words, saying I want the infant returned to me), this Probate Court would conduct a hearing to determine the best interests of the child. Determining the best interests of the child would be based upon the relevant factors, including but not limited to those set forth in Section 3107.161. I understand that this Court could find that allowing me to withdraw my consent and regain custody of the child is not in the child's best interests and that I would not receive the child back. Therefore, I understand that I am giving up significant rights and control concerning this child today. 8. I understand that the Final Decree of Adoption is subject to appeal by me to the court of appeals for this county. However, I am giving up the right to receive notice of any hearing, or of the issuance of either the Interlocutory or Final Decree of Adoption, and therefore will not know specifically when my rights of appeal may expire. I understand that the Final Decree of Adoption should be granted no sooner than six months after the court approves placement and that the normal right of appeal would expire 30 days from that day. If I have any questions concerning contesting this adoption in any manner, I understand that I should immediately contact the Court and/or legal counsel. 9. I understand that subject to the disposition of an appeal, upon the expiration of one year after a Final Decree of Adoption is issued, the decree cannot be questioned by American LegalNet, Inc. www.FormsWorkFlow.com any person, in any manner, or upon any ground, including fraud, misrepresentation, failure to give any required notice, or lack of jurisdiction of the parties or subject matter. 10. I understand that the effect of the Interlocutory or the Final Decree of Adoption is the termination of all legal relationships between me and the child. The prospective adoptive parents will be established as the legal parents of this child, having the full and complete rights to determine the values and upbringing of the child, including but not limited to, the child of religious training, education, and discipline. 11. The biological or natural father of this child has not been judicially determined. ______ [initial]. I know of no person,