in the circuit court for the twenty-third judicial...

IN THE CIRCUIT COURT FOR THE TWENTY-THIRD

JUDICIAL CIRCUIT

DEKALB COUNTY, ILLINOIS

_________________________________ ) CASE NO. _______________________________

_________________________________ )

Petitioner(s), )

)

vs. )

__________________________________ )

__________________________________ )

Respondent(s).

ACKNOWLEDGEMENT OF INFORMATION ON THE ILLINOIS ADOPTION

REGISTRY AND MEDICAL INFORMATION EXCHANGE

I, _________________________________ have signed the Final and Irrevocable Consent to Adoption (relationship, e.g., mother, father, guardian)

for a child born on _____________________________ at ____________________________________.

I have been given the Illinois Department of Public Health “Illinois has put the option back in adoption”

which provides information on the Illinois Adoption Registry and Medical Information Exchange.

_______________________________________________________

Name

___________________________________________, 20_________

Date

Acknowledgement of IL Adoption Registry & Medical Info

04-01-16 lks

Petition for Adoption/p.1

Rev. 04-01-16

IN THE CIRCUIT COURT OF THE TWENTY-THIRD

JUDICIAL CIRCUIT


____________________________________________

____________________________________________

Petitioner(s),

vs.

____________________________________________

____________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

CASE NO.________________________________

PETITION FOR ADOPTION

NOW COME(S) Petitioner(s) herein and allege as follows:

(a) The full name(s) of the Petitioner(s) and, if minor(s), his/her respective age(s) is/are as follows:

Name_________________________________________________________________________________ Age__________

Name_________________________________________________________________________________ Age__________

(b) The place of residence of Petitioner(s) and the length of residence in Illinois (of each) immediately preceding

the filing of the within Petition is/are as follows:

Place_______________________________________________________________________________ Length__________

Place_______________________________________________________________________________ Length__________

(c) The Petitioners(s) acquired/intend(s) to acquire custody of said child from _____________________________

____________________________________whose address is__________________________________________________

______________________________________________________on_________________________, 20_____.

(d) The name, place, date of birth and sex of the child sought to be adopted is as follows:____________________

____________________________________________________________________________________________________

.

(e) The relationship, if any, of the child to each Petitioner is as follows:__________________________________

____________________________________________________________________________________________________

(f) The names of the parents of the child, place of residence and whether minor or adult are as follows:

Father ___________________________________ Age__________

Residence_____________________________________

Mother ___________________________________ Age__________

Residence_____________________________________

Neither of the parents are under any legal disability except:______________________________________________

____________________________________________________________________________________________________

(1) The rights of the parents have been terminated by _____________________________________________,

a court of competent jurisdiction.

(2) The child has been surrendered to the following agency: ________________________________________

____________________________________________________________________________________________________


Rev. 04-01-16

(3) The parent(s), namely____________________________________________________________________

has/have been served with the notice provided in Section 12a of this Act and ________________________

__________________________________ has filed ___________________________________________

(g) The child has no living parent(s). The legal guardian of the child is __________________________________

who was appointed by _________________________________________________________________________________

(h) The child has no living parent(s) and no legal guardian is known. The name of a near relative is

_________________________ Relationship____________________ Address_____________________________________

____________________________________________________________________________________________________

(i) The name to be given the child (adult) is _______________________________________________________

(j) (1) That ______________________________________________, being the person/agency having authority

to do so, has/have consented/indicated a willingness to consent to the adoption of the child by the Petitioner(s).

(2) That ______________________________________________, has authority to consent to the adoption

of the child by Petitioner(s), is an/are unfit person(s) for the following reason(s):

____________________________________________________________________________________________________

(k) Orders, judgments or decrees have been entered affecting:

(1) The adoption or custody of the child as follows:______________________________________________

____________________________________________________________________________________________________

(2) The adoptive, custodial or parental rights of either Petitioner as follows, including the prior denial of any

petition for adoption pertaining to such child, or to the Petitioner(s) or either of

them:_______________________________________________________________________________________________

____________________________________________________________________________________________________

(3) Additional allegation(s) required by the facts of this particular

case:________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

WHEREFORE, Petitioner(s) pray(s) that the above-named _____________________________________________

may be made Respondent(s) to this Petition, and that a Summons may issue for them and each of them, returnable according

to law, and that they and each of them be required to answer this petition as is by statute provided.

Petitioner(s) further pray(s) that the court will, on the final hearing of this Petition, ORDER, ADJUDGE and

DECREE that the said ______________________________ shall, to all legal intents and purposes, be the child of your

Petitioner(s), and that the name of said child shall thereafter be _________________________________________________

____________________________________________________________________________________________________

That this Honorable Court will make such other and further orders in the premises as may be in accordance with the

law.

__________________________________________ _____________________________________________

Signature of Petitioner Signature of Petitioner

__________________________________________ _____________________________________________

Petitioner (type or print name) Petitioner (type or print name)


Rev. 04-01-16

STATE OF ILLINOIS )

) SS.

County of _________________ )

_______________________________________________, being first duly sworn upon oath depose(s) and say(s) that he/she

has read and signed the foregoing Petition and that the contents thereof are true and correct.

Name:________________________________________

Attorney for:___________________________________

Address:______________________________________

City/State/Zip:

_____________________________________________

Telephone:_____________________________________

____________________________________________

Signature of Petitioner

____________________________________________

Signature of Petitioner

Signed and sworn to before me this __________ day of

__________________________, 20______________.

____________________________________________

Notary Public

Summons - Adoption

Rev. 04-01-16/p.1


JUDICIAL CIRCUIT


__________________________________________________

__________________________________________________

Plaintiff(s)/Petitioner(s),

vs.

__________________________________________________

__________________________________________________

Defendant(s)/Respondent(s).

)

)

)

)

)

)

)

)

)

CASE NO. ____________________________

SUMMONS - ADOPTION

TO EACH DEFENDANT:

YOU ARE SUMMONED and required to file an answer in this case, or otherwise file your appearance in the Office of the

Circuit Clerk of this Court, located at 133 West State Street, Room 203, Sycamore, Illinois, within thirty (30) days after service of this

Summons, not counting the day of service. IF YOU FAIL TO DO SO, A JUDGMENT OR DECREE BY DEFAULT MAY BE TAKEN

AGAINST YOU FOR THE RELIEF ASKED IN THE COMPLAINT.

To the Officer:

This Summons must be returned by the Officer or other person to whom it was given for service, with endorsement of service and

fees, if any, immediately after service. If service cannot be made, this Summons shall be returned so endorsed.

This Summons may not be served later than thirty (30) days after its date.

(Seal of Court) WITNESS,___________________________, 20________

________________________________________________

Clerk of the Circuit Court

(Petitioner(s) Attorney or Petitioner if he/she is not represented by an attorney)

Name: __________________________________________

Attorney for: __________________________________________

Attorney Number: __________________________________________

Address: __________________________________________

City/State/Zip: __________________________________________

Telephone No.: __________________________________________

Date of Service ________________________, 20___

(To be inserted by Officer or Process Server on the copy left with the Respondent or other person)

Summons - Adoption

Rev. 04-01-16/p.2

SHERIFF'S FEES: Service and return $__________ + _______ Miles at $__________ per mile = total $__________.

Sheriff of _______________________________County

By:_______________________________________, Deputy

I certify that I served this Summons on defendant(s) as follows:

(a) - (Individual defendant(s)-personal):

(The officer or other person making service, shall (a) identify as to sex, race and approximate age of the defendant with whom she/he left

the Summons, and (b) state the place where (whenever possible in terms of an exact street address) and the date and time of day when the

Summons was left with the Defendant.)

DEFENDANT NAME ADDRESS WHERE SERVED DATE OF SERVICE SEX/RACE/APPROXIMATE AGE

(b) - (Individual defendant(s)-abode):

By leaving a copy of the Summons and Complaint at the usual place of abode of each individual defendant with a person of his family, of

the age of 13 years or upwards, informing that person of the contents of the Summons, and also by sending a copy of the Summons. (The

officer or other person making service, shall (a) identify as to sex, race and approximate age of the person, other than the Defendant, with

whom she/he left the Summons, and (b) state the place where (whenever possible in terms of an exact street address) and the date and time

of day when the Summons was left with the person.)

NAME OF PERSON SERVED ADDRESS WHERE SERVED DATE OF SERVICE SEX/RACE/APPROXIMATE AGE

Also, by sending a copy of the Summons and Complaint in a sealed envelope with postage fully prepaid, addressed to each individual

Defendant at his usual place of abode, as follows:

DEFENDANT NAME MAILING ADDRESS DATE OF MAILING

(c) - Corporation defendant(s):

By leaving a copy of the Summons and Complaint with the registered agent, officer or agent of each Defendant corporation, as follows:

DEFENDANT CORPORATION REGISTERED AGENT, OFFICER OR AGENT DATE OF SERVICE

(d) - (Other service):

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Sheriff of _____________________________County

By:_________________________________, Deputy


JUDICIAL CIRCUIT


NEW CASE INFORMATION SHEET

County of Kendall ) SS. CASE NO.________________________

County of DeKalb )

1. Case Type:____________ 2. Sub Case Type:________ 3. Claim Amount: $___________ 4. Jury: _________ (see reverse for codes) (see reverse for codes) (yes/no)

5. Domestic Relations cases only contested: _____________________ Date of Birth:______________________ (yes or no - if applicable) (juvenile case)

6. Event Date/Time:________________________________________ 7. Is real estate involved?_______________ (month) (date) (year) (yes/no)

8. First named plaintiff:_________________________________________________________________________

Address:__________________________________________ Address #2:______________________________

City:__________________________ State/Zip Code:__________________ Phone #:___________________

9. Plaintiff Attorney:____________________________________________________________________________ (State of Illinois Registration Number)

Name:_____________________________________________________________________________________ (Last) (First) (MI)

10. First named defendant:______________________________________________________________________

Address:________________________________________ Address #2:______________________________

City:________________________ State/Zip Code:__________________ Phone #:___________________

11. Second named plaintiff:______________________________________________________________________

Address:________________________________________ Address #2:______________________________

City:_______________________ State/Zip Code:__________________ Phone #:___________________

12. Second named defendant:_________________________________________ ___________________________

Address:________________________________________ Address #2:______________________________

City:_______________________ State/Zip Code:__________________ Phone #:___________________

13. List additional Plaintiffs by name, address, city, zip code &

phone # below (including AKAs & DBAs).

(Domestic Relations): List children under 18 by

name and DOB. Attach additional sheet if needed.

New Case Information Sheet

REV. 04-01-16

14. List additional Defendants by name, address, city, zip

code & phone # below (including A.K.A.’s &

D.B.A’s). Attach additional sheet if needed.

CIVIL CASE & SUB-CASE TYPE CODES

Law (L) ($50,001 and over)

0101 TORT $ DAMG AUTO - PROP

0102 TORT $ DAMG AUTO - PROP/PER INJ

0103 TORT $ DAMG AUTO - PER INJ

0104 TORT $ DAMG AUTO - PER INJ/DEATH

0105 TORT $ DAMG AUTO - DEATH

0106 TORT $ DAMG - OTHER

0107 CONTRACT - MONEY DAMAGES

0108 CONFESSION OF JUDGMENT

0109 FORCE ENTRY/DETAINER - POSS/$

0110 FORCE ENTRY/DETAINER - POSS ONLY

0111 DISTRESS FOR RENT

0112 STAT ACT / STATE / RECR SUPPT

0113 ARBITRATION & AWARD

0114 DETINUE

0115 EJECTMENT

0116 REPLEVIN

0117 TROVER

0118 MALPRACTICE - MEDICAL

0119 MALPRACTICE - LEGAL

0120 MALPRACTICE - OTHER

0121 ALIENATION OF AFFECTION

0122 CLASS ACTION SUIT

0123 REGISTRATION OF FOREIGN JUDG

0130 OTHER (SPECIFY)

Law Medium (LM) ($10,001 to $50,000)

0201 TORT - $ DAMG - AUTO - PROP

0202 TORT - $ DAMG - AUTO - PROP/PER INJ

0203 TORT - $ DAMG - AUTO - PER INJ

0204 TORT - $ DAMG - AUTO - PER INJ/DEATH

0205 TORT - $ DAMG - AUTO - DEATH

0206 TORT - $ DAMG - OTHER

0207 CONTRACT MONEY DAMAGES

0208 CONFESSION OF JUDGMENT

0210 FORCIBLE ENTRY / DETAINER POSS/$

0211 DISTRESS FOR RENT

0212 STAT ACT / STATE / RECR SUPPT

0213 ARBITRATION & AWARD

0214 DETINUE

0215 EJECTMENT

0216 REPLEVIN

0217 TROVER

0218 MALPRACTICE - MEDICAL

0219 MALPRACTICE - LEGAL

0220 MALPRACTICE - OTHER

0221 ALIENATION OF AFFECTION

0222 CLASS ACTION SUIT



Small Claims (SC) (up to $10,000)

0301 CONTRACT - MONEY - DAMAGES

0302 TORT - $ DAMG - AUTO

0303 TORT - $ DAMG - OTHER

0304 TAX COLLECTION



Eminent Domain (ED)

0501 CONDEMNATION


Mental Health (MH)

1101 PETN FOR HOSPITALIZATION

1102 PETN FOR DISCHARGE

1103 PETN FOR RESTORATION

1104 AUTH EMGCY MED/DENTAL TRETMNT

1105 AUTH PSYCHOTROPIC MEDICATION

1106 ADMINISTRATOR TO ADMIN TRETMNT


Miscellaneous Remedies (MR)

0601 JUDICIAL REVIEW / ADMIN

0602 JUDICIAL REVIEW / WORKERS COMP

0603 JUDICIAL REVIEW / UNEMPLOYMENT

0604 DECLARATORY JUDGMENT

0605 CORPORATION DISSOLUTION

0606 CHANGE OF NAME

0607 HABEAS CORPUS

0608 MANDAMUS

0609 PROHIBITION

0610 QUO WARRANTO

0611 ATTACH/ORIGINAL ACTION

0612 NE EXEAT / ORIGINAL ACTION

0613 ESCHEAT

0614 LOST GOODS OR MONEY

0615 BURNT RECORDS

0616 ELECTION CONTEST

0617 DISCOVERY

0618 SEARCH WARRANT

0619 FORFEITURE OF SEIZED PROPERTY

0620 CONTEMPT OF COURT

0621 REG OF FICTITIOUS RECORD

0622 SEX TRANSMISS DISEASE CONTROL

0623 CONTAGIOUS/ INFECTIOUS DISEASE


0625 PETN ISSUE FOREIGN SUBPOENA

0626 EASVESDROPPING/CRIMINAL SURVEY

0627 DEMOLITION

0628 EXTRADITION


0631 SEXUALLY VIOLENT PERSONS ACT

0635 ANNEXATION

Chancery (CH)

0701 INJUNCTION (EXCEPT TX OR D CASES)

0702 RESIDENTIAL REAL ESTATE MORTG

FORECLOSURE

0703 MECHANIC LIEN FORECLOSE

0704 FORECLOSURE SEC / INTEREST /

PERS-PROP

0705 PARTNERSHIP DISSOLUTION

0706 SPECIFIC PERFORMANCE

0707 PARTITION

0710 CONST / INTER VIVOS TRUST

0711 CONST / TESTAMENTARY TRUST

0712 TRUST ADMINISTRATION

0713 QUIET TITLE

0714 COMPLAINT IN EQUITY

0715 ACCOUNTING

0716 RECEIVERSHIP

0717 RECESSION OF CONTRACT

0718 CREDITOR’S COMPLAINT

0719 UNIFORM GIFT TO MINOR ACT

0720 SETTING ASIDE A DEED

0721 FORECLOSURE ON CONDO ASSMT

0722 INTERPLEADER


0724 STRUCTURED SETLMNT (ORIG ACT

TO ASSIGN)


0731 BUSINESS REAL ESTATE MORTG

FORECLOSURE

Tax (TX)

0401 REC OF DELIN PERS PROP TAXES

0402 RETAILERS OCCUPATION TAX

0403 PETITION FOR TAX REFUND

0404 TAX FORECLOSURE

0405 TAX INJUNCTION

0406 ANNUAL TAX SALE

0407 SCAVENGER TAX SALE

0408 TAX OBJECTION

0409 TAX COMMISSION (REV DEC)

0410 DRAINAGE ASSESSMENT

0411 SPECIAL ASSESSMENT

0412 FORECLOSE LIEN/ SPEC ASSMT

0413 SUIT / RESTRAIN COLL / SPEC ASSMT

0414 TAX DEED

0415 PETITION FOR RECOVERY


0417 SALE IN ERROR


Municipal Corporation (MC)

1301 PETN /ORGANIZE MUN CORP

1302 PETN /DISSOLVE MUN CORP

1303 PETN /CREATION OF DRAINAGE

1304 PETN /CHANGE OF GOVERNMENT


Adoption (AD)

0801 ADOPTION

0817 ADOPTION UNBORN CHILD

Divorce (D)

0901 DISSOLUTION

0902 INVALIDITY

0903 LEGAL SEPARATION

0906 SIMPLIFIED DISSOLUTION


0908 DISSOLUTION – CIVIL UNION


Family (F)

0802 PUTATIVE FATHER

0803 PATERNITY

0804 PARENT & CHILD RELATIONSHIP

0806 RECIPROCAL NON-SUPPORT

0807 NEGLECT & REFUSAL TO SUPPT

0808 CIVIL ACTION TO COMPEL SUPPORT

0809 URESA - INCOMING

0810 URESA - OUTGOING


0812 MEDICAL ASST NO GRANT (MANG)

0813 PATERNITY (MANG)

0814 NEGLECT & REFUSAL TO SUPPT (MANG)

0815 URESA - INCOMING (MANG)

0816 URESA - OUTGOING (MANG)

0818 CONFIDENTIAL INTERMEDIARY


0904 PETITION FOR CUSTODY

0905 PETITION FOR VISITATION

1005 EMANCIPATION

1006 ORDER FOR MARRIAGE LICENSE

Order of Protection (OP)

0805 ORDER OF PROTECTION


0822 CIVIL NO CONTACT ORDERS

0823 STALKING NO CONTACT ORDERS

Juvenile (J)

1002 SUPERVISION

1003 DEPENDENCY

1007 ADDICTED MINOR

1008 TRUANCY

1009 MINOR REQ AUTH INTERVENTION

1010 TEMPORARY GUARDIAN


Juvenile Neglect and Abuse (JA)

1004 NEGLECT AND ABUSE

Juvenile Delinquency (JD)

1001 DELINQUENCY

Final & Irrevocable Consent to Adoption

Rev. 04-01-16


JUDICIAL CIRCUIT


_______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

CASE NO. ______________________________

FINAL AND IRREVOCABLE CONSENT TO ADOPTION

I, ______________________________________________ of _________________________________________________ (relationship, e.g. mother, father, guardian)

a female/male child, state:

That such child was born on ________________________ at _________________________________________________.

That I reside at ______________________________________________________________________________________,

County of __________________________________________ and State of _____________________________________________.

That I am of the age of ____________ years.

That I hereby enter my appearance in this proceeding and waive service of summons on me.

That I hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and Responsibilities – Private

Form before signing this consent and that I have had time to read, or have had read to me, this form. I understand that if I do not

receive any of the rights as described in this form, it shall not constitute a basis to revoke this Final and Irrevocable Consent.

That I do hereby consent and agree to the adoption of such child.

That 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 such child.

THAT I UNDERSTAND SUCH 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 SUCH CHILD. THAT I HAVE READ

AND UNDERSTAND THE ABOVE AND I AM SIGNING IT AS MY FREE AND VOLUNTARY ACT.

Dated this__________ day of ________________, 20_____. _______________________________________________

STATE OF ILLINOIS )

) SS.

County of _________________ )

I,_________________________________________, do hereby certify that_______________________________________

personally known to me to be the same person whose name is subscribed to the foregoing consent, appeared before me this day in

person and acknowledged that he/she signed and delivered such consent as her/his free and voluntary act, for the specified purpose.

I have fully explained that by signing such consent he/she is irrevocably relinquishing all parental rights to such child or adult

and he/she has stated that such is his/her intention and desire.

In Witness Whereof, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.

________________________________________________

Consent by Adult to Adoption

Rev. 04-01-16


JUDICIAL CIRCUIT


_______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

CASE NO. ______________________________

CONSENT BY ADULT OR CHILD

OF THE AGE OF FOURTEEN YEARS OR OVER TO ADOPTION

I, ______________________________________________________________, state:

That I reside at __________________________________________________________, County of_____________________________

and State of _______________________________________.

That I hereby enter my appearance in this proceeding and waive service of summons on me.

That I am of the age of ____________ years.

That I consent and agree to my adoption by ________________________________________________________________________ and

_________________________________________________.

Dated this__________ day of __________________________, 20_______. _______________________________________________

STATE OF ILLINOIS )

) SS.

COUNTY OF ___________________ )

I, ________________________________________________________________________________________, do hereby certify that

(Name and Official Capacity)

________________________________________ personally known to me to be the same person whose name is subscribed to the foregoing consent,

appeared before me this day in person and acknowledged that he/she signed and delivered such consent as her/his voluntary act, for the specified

purpose.

I have fully explained that by signing such consent he/she is irrevocably electing to become, to all legal intents and purposes, the child of

the Petitioner _____ named in said Petition, and he/she has stated that such is his/her intention or desire.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.

_______________________________________________

_______________________________________________

STATE OF ILLINOIS )

) SS.

COUNTY OF ___________________ )

I, ____________________________________________________, a Notary Public in and for said County, in the State aforesaid, do

hereby certify that the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me this day in person

and acknowledged that he/she signed such certificate as his/her voluntary act and that the statements made in said certificate are true.

Given under my hand and notarial seal this ___________ day of _____________________, 20_______.

(Official Seal) _______________________________________________

Notary Public


JUDICIAL CIRCUIT


_______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

)

CASE NO. ______________________________

CONSENT TO ADOPTION OF ADULT

I, ______________________________________________________________, father/mother of _______________________________,

an adult, state:

That I reside at __________________________________________________________, County of_____________________________

and State of _______________________________________.

That I am of the age of __________ years. That I hereby enter my appearance in this proceeding and waive service of summons on me.

That I do hereby consent and agree to the adoption of such adult by _______________________________________________________

and _________________________________________________.

Dated this__________ day of __________________________, 20_____. _______________________________________________

STATE OF ILLINOIS )

) SS.

COUNTY OF ___________________ )

I,__ ________________________________________________________________________________________, do hereby certify that

(Name and Official Capacity)

________________________________________ personally known to me to be the same person whose name is subscribed to the foregoing consent,

appeared before me this day in person and acknowledged that he/she signed and delivered such consent as his/her free and voluntary act, for the

specified purpose.

I have fully explained that by signing such consent he/she is irrevocably relinquishing all parental rights to such adult and he/she has stated

that such is his/her intention or desire.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____________________, 20_______.

_______________________________________________

_______________________________________________

STATE OF ILLINOIS )

) SS.

COUNTY OF ___________________ )

I, ____________________________________________________, a Notary Public in and for said County, in the State aforesaid, do

hereby certify that the same person whose name is subscribed to the foregoing certificate of acknowledgment, appeared before me this day in person

and acknowledged that he/she signed such certificate as his/her voluntary act and that the statements made in said certificate are true.

Given under my hand and notarial seal this ___________ day of _____________________, 20_______.

(Official Seal)

_______________________________________________

Notary Public Consent to Adoption of Adult

Rev. 04-01-2016

Final & Irrevocable Surrender-Adoption

Rev. 04-01-16/p.1


JUDICIAL CIRCUIT

DEKALB COUNTY, ILLINOIS _______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

)

)

CASE NO._______________________________

FINAL AND IRREVOCABLE SURRENDER FOR PURPOSES OF ADOPTION I, _________________________________________of ____________________________________________,

(relationship)

a ___male child, state: That such child was born on ________________________________________________ at _______________.

That I reside at ______________________________________________________________________,

County of ___________________________ and State of _________________________.

That I am of the age of __________ years.

That I do hereby surrender and entrust the entire custody and control of such child to the

_________________________________________________________________________________________________ (Agency)

a (public) (licensed) child welfare agency with its principal office in the City of __________________________________,

County of _______________________________________, and State of ________________________________________,

for the purpose of enabling it to care for and supervise the care of such child, to place such child for adoption and to consent

to the legal adoption of such child.

That I hereby grant to said Agency full power and authority to place such child with any person or persons it may

in its sole discretion select to become the adopting parent or parents and to consent to the legal adoption of such child by

such person or persons; and to take any and all measures which, in the judgment of said Agency, may be for the best

interests of such child, including authorizing medical, surgical and dental care and treatment including inoculation and

anesthesia for such child.

That I wish to and understand that by signing this surrender I do irrevocably and permanently give up all custody

and other parental rights I have to such child.

THAT I UNDERSTAND I CANNOT UNDER ANY CIRCUMSTANCES, AFTER SIGNING THIS

SURRENDER, CHANGE MY MIND AND REVOKE OR CANCEL THIS SURRENDER OR OBTAIN OR

RECOVER CUSTODY OR ANY OTHER RIGHTS OVER SUCH CHILD.

That I have read and understand the above and I am signing it as my free and voluntary act.

______________________________________ ____________________________________________

Signature Witness

Dated this ________ day of _________________________, 20_____.

Final & Irrevocable Surrender-Adoption

Rev. 04-01-16/p.2

STATE OF ILLINOIS

SS.

COUNTY OF DEKALB

I,

_________________________________________________________________________________________,

(name and official title)

do hereby certify that ______________________________________, personally known to me to be the same

person whose name is subscribed to the foregoing Surrender, appeared before me this day in person and

acknowledged that (she) (he) signed and delivered such Surrender as (her) (his) free and voluntary act, for the

specified purpose.

I have fully explained that by signing such consent (she) (he) is irrevocably relinquishing all parental

rights to such child or adult and (she) (he) has stated that such is (her) (his) intention and desire.

In Witness Whereof, I have hereunto affixed my signature this ______ day of ____________________,

20 _____.

STATE OF ILLINOIS

SS.

COUNTY OF DEKALB

I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that

_________________________________, personally known to me to be the same person whose name is

subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged

that (she) (he) signed such certificate as (her) (his) free and voluntary act and that the statements made in said

certificate are true.

Given under my hand and notarial seal this ______ day of _____________________________, 20____.

(OFFICIAL SEAL) ____________________________________________

Notary Public

Final & Irrevocable Consent to Adoption-DCFS Case Rev. 04-01-16/p.1


JUDICIAL CIRCUIT


IN THE MATTER OF THE ADOPTION OF: ) CASE NO. ____________________________

)

)

)

____________________________________ )

A Minor

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY

A SPECIFIED PERSON OR PERSONS: DCFS CASE

I, __________________________________, the mother/father of ________________________

a male/female child, state that:

1. My child, ____________________________________, was born on ________________

at _____________________________ Hospital in the municipality of _______________

in ___________________________ County, State of ____________________________.

2. I reside at ______________________________________________________, County of

________________________, State of _________________________ Zip Code ______.

Mail may also be sent to me at this address: _______________________________________

In care of: __________________________________________________________________

My home telephone number is: _________________________________________________

My cell telephone number is: ___________________________________________________

My e-mail address is: _________________________________________________________

3. I, _______________________________________, am ________________ years of age.

4. I enter my appearance in this action for my child to be adopted by the person or persons

specified herein by me and waive service of summons on me in this action only.

5. I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and

Responsibilities in Illinois for Final and Irrevocable Consents to Adoption by a Specified

Person or Persons for DCFS Cases before signing this Consent and that I have had time

to read this form, or have it read to me, and that I understand the rights and

responsibilities described in this form. I understand that if I do not receive any of my

rights as described in this form, it shall not constitute a basis to revoke this Final and

Irrevocable Consent to Adoption by a Specified Person or Persons.

6. I do hereby consent to the adoption of such child by _____________________________

________________________________________ only.


7. I wish to sign this Consent and I understand that by signing this Consent, I irrevocably

and permanently give up all my parental rights I have to my child.

8. I understand that this Consent allows my child to be adopted by ____________________

________________________ only and that I cannot under any circumstances, after

signing this document, change my mind and revoke or cancel this Consent.

If the parent consents to an adoption by two specified persons, complete the following:

8a. I understand that if ____________________________________________________ and

___________________________________ get a divorce or are granted a dissolution of a

civil union before the petition to adopt my child is granted, this Consent remains valid for

_________________________________________________ (identify specified person)

to adopt my child. I understand that I cannot change my mind and revoke this consent or

obtain or revoke custody over my child if __________________________________ and

_______________________________________ divorce or are granted a dissolution of a

civil union.

8b. I understand that if either _________________________________________________ or

____________________________________ dies before the petition to adopt my child is

granted, this Consent remains valid for the surviving person to adopt my child. I

understand that I cannot change my mind and revoke this Consent or obtain or recover

custody over my child on the basis that one of the specified persons dies.

9. I understand that this Consent will be void if:

a. the Department places my child with someone other than the specified person or

persons; or

b. a court denies the adoption petition for the person or persons to adopt my child; or

c. the DCFS Guardianship Administrator refuses to consent to my child’s adoption by

the specified person or persons on the basis that the adoption is not in my child’s best

interest.

I understand that if this consent is void, I have parental rights to my child, subject to any

applicable court orders including those entered under Article II of the Juvenile Court Act

of 1987, unless and until I sign a new consent or surrender or my parental rights are

involuntarily terminated. I understand that if this Consent is void, my child may be

adopted by someone other than the specified person or persons only if I sign a new

consent or surrender, or my parental rights are involuntarily terminated. I understand that

if this Consent is void, the Department will notify me within 30 days using the addresses

and telephone numbers I provided in paragraph 2 of this form. I understand that if I

receive such notice, it is very important that I contact the Department immediately and

preferably within 30 days, to have input into the plan for my child’s future.

10. I understand that if a petition for adoption of my child is filed by someone other than ___

_________________________________________, the Department will notify me within

14 days after the Department becomes aware of the petition. If someone other than ____

_________________________________________ (specified person(s)) files a petition to

adopt my child, this consent remains valid only for ______________________________

(specified person(s)) to adopt by child.


11. If a person(s) other than the specified person or persons files a petition to adopt my child

or if the consent is void under paragraph 9, the Department will send written notice to me

using the mailing address and email address provided by me in paragraph 2 of this form.

The Department will also contact me using the telephone numbers I provided in

paragraph 2 of this form. It is very important that I let the Department know if any of my

contact information changes. If I do not let the Department know of any of my contact

information changes, I understand that I may not receive notification from the

Department if this Consent is void or if someone other than the specified person or

persons files a petition to adopt my child. If any of my contact information changes, I

should immediately notify:

Caseworker’s name and telephone number:

______________________________________________________________________________

Agency name, address, zip code and telephone number:

______________________________________________________________________________

Supervisor’s name and telephone number:

______________________________________________________________________________

DCFS Advocacy Office for Children and Families: 1-800-232-3798 or 1-217-524-2029

12. I expressly acknowledge that paragraph 9 (and paragraphs 8a and 8b, if applicable) does

not impair the validity and finality of this Consent under any circumstance.

13. I have read and understand the above and I am signing it as my free and voluntary act.

Dated this ___________________________ day of ___________________________, 20 _____

__________________________________________

Signature



JUDICIAL CIRCUIT


STATE OF ___________________________ ) CASE NO. ____________________________

)

)

COUNTY OF _________________________ )

CERTIFICATE OF ACKNOWLEDGEMENT OF CONSENT

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A

SPECIFIED PERSON OR PERSONS: DCFS CASE

I, ____________________________________________________________ (name of Judge or

other person), _____________________________________________________ (official title,

name and address), certify that ____________________________________________________

personally known to me to be the same person whose name is subscribed to the foregoing Final

and Irrevocable Consent for Adoption by a Specified Person or Persons, DCFS case, appeared

before me this day in person and acknowledged that (she) (he) signed and delivered such

Consent as a free and voluntary act, for the specified purpose.

I have fully explained that by signing this consent this parent is irrevocably and permanently

relinquishing all parental rights to the child so that the child may be adopted by a specified

person and persons, and this parent has stated that such is (her) (his) intention and desire. I have

fully explained that this consent is void only if:

1. The placement is disrupted and the child is moved to a different placement; or

2. A court denies the petition for adoption; or

3. The Department of Children and Family Services Guardianship Administrator refuses to

consent to the child’s adoption by a specified person or persons on the basis that the

adoption is not in the child’s best interests.

Dated this ________ day of _________________, 20 _______.

___________________________________________________

Signature


STATE OF ___________________________ )

) SS.

COUNTY OF _________________________ )

ACKNOWLEDGEMENT OF SIGNATURE

I, _________________________________________________, Notary Public, in and for said

County and State, to hereby certify that _____________________________________________,

personally known to me to be the same person whose name is subscribed in the foregoing

Certificate of Acknowledgement, appeared before me in person this date and acknowledged that

(she) (he) signed such as (her) (his) free and voluntary act and that the statements made in said

certificate are true.

Given under my hand a notarial seal this ________ day of ______________________, 20 _____.

_________________________________________ Notary Public

(Seal)


BIRTH PARENT RIGHTS AND RESPONSIBILITIES-PRIVATE

FORM (750 ILCS 50/10)

As a birth parent in the State of Illinois, you have the right:

1. To have our own attorney represent you. The prospective adoptive parents may agree to

pay for the cost of your attorney in a manner consistent with Illinois law, but they are not

required to do so.

2. To be treated with dignity and respect at all times and to make decisions free from

coercion and pressure.

3. To receive counseling before and after signing a Final and Irrevocable Consent to

Adoption (“Consent”), a Final and Irrevocable Consent to Adoption by a Specified

Person or Persons: Non-DCFS Case (“Specified Consent”), or a Consent to Adoption of

Unborn Child (“Unborn Consent”). The prospective adoptive parents may agree to pay

for the cost of counseling in a manner consistent with Illinois law, but they are not

required to do so.

4. To ask to be involved in choosing your child’s prospective adoptive parents and to ask to

meet them.

5. To ask your child’s prospective adoptive parents any questions that pertain to your

decision to place your child with them.

6. To see your child before signing a Consent or Specified Consent.

7. To request contact with your child and/or the child’s prospective adoptive parents, with

the understanding that any promises regarding contact with your child or receipt of

information about the child after signing a Consent, Specified Consent, or Unborn

Consent cannot be enforced under Illinois law.

8. To receive copies of all documents that you sign and have those documents provided to

you in your preferred language.

9. To request that your identifying information remain confidential, unless required

otherwise by Illinois law or court order, and to register with the Illinois Adoption

Registry and Medical Information Exchange.

10. To work with an adoption agency or attorney of your choice, or change said agency or

attorney, provided you promptly inform all of the parties currently involved.

11. To receive, upon request, a written list of any promised support, financial or otherwise,

from your attorney or the attorney for your child’s prospective adoptive parents.


12. To delay signing a Consent, Specified Consent, or Unborn Consent if you are not ready

to do so.

13. To decline to sign a Consent, Specified Consent, or Unborn Consent even if you have

received financial support from the prospective adoptive parents.

If you do not receive any of the rights described in this Form, it shall not be a basis to revoke

Consent, Specified Consent, or Unborn Consent.

As a Birth Parent in the State of Illinois, you have the responsibility:

1. To carefully consider your reasons for choosing adoption.

2. To voluntarily provide all known medical, background, and family information about

yourself and your immediate family to your child’s prospective adoptive parents or their

attorney. For the health of your child, you are strongly encouraged, but not required, to

provide all known medical, background, and family history information about yourself

and your family to your child’s prospective adoptive parents or their attorney.

3. (Birth mothers only) To accurately complete an Affidavit of Identification, which

identifies the father of the child when known, with the understanding that a birth mother

has a right to decline to identify the birth father.

4. To not accept financial support or reimbursement of pregnancy related expenses

simultaneously from more than one source.

______________________________________

Initials

Final & Irrevocable Consent to Adoption-Non-DCFS Rev. 04-01-16/p.1


JUDICIAL CIRCUIT


IN THE MATTER OF THE ADOPTION OF: ) CASE NO. _______________________________

)

)

____________________________________ )

A Minor

FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY

A SPECIFIED PERSON OR PERSONS: NON-DCFS CASE

I, _______________________________________________________ state:

1. That I am the mother/father of _______________________________________________

a male/female child born on ___________________________________________, at

________________________________, City of ________________________________

and State of _____________________________.

2. That I reside at _______________________________________________, County of

____________________________ and State of ________________________________.

3. That I am the age of ____________________ years.

4. That I hereby enter my appearance in this proceeding and waive service of summons on

me.

5. That I hereby acknowledge that I have been provided a copy of the Birth Parents Rights

and Responsibilities-Private Form before signing this Consent and that I have had time

to read, or have had read to me, this Form and that I understand the Rights and

Responsibilities described in this Form. I understand that if I do not receive any of my

rights as described in said Form, it shall not constitute a basis to revoke this Final and

Irrevocable Consent to Adoption by a Specified Person.

6. That I do hereby consent and agree to the adoption of such child by ________________

______________________________________________________________ (specified

person or persons) only.

7. That I wish to and understand that upon signing this consent I do irrevocably and

permanently give up all custody and other parental rights I have to such child if such

child is adopted by ______________________________________________________

(specified person or persons). I hereby transfer all of my rights to the custody, care and

control of such child to ___________________________________________________

___________________________________ (specified person or persons).

8. That I understand such child will be adopted by ________________________________

___________________________________ (specified person or persons) and that I

cannot under any circumstances, after signing this document, change my mind and evoke


or cancel this consent or obtain or recover custody or any other rights over such child if

________________________________________________________________________

(specified person or persons) adopt(s) such child; PROVIDED that each specified person

has filed, or shall file, within 60 days from the date hereof, a petition for the adoption of

such child.

9. That if the specified person or persons designated herein do not file a petition for

adoption within the time-frame specified above, or, if said petition for adoption is filed

within the time-frame specified above but the adoption petition is dismissed with

prejudice or the adoption proceeding is otherwise concluded without an order declaring

the child to be the adopted child of the specified person or persons, then I understand that

I will receive written notice of such circumstances within 10 business days of their

occurrence. I understand that the notice will be directed to me using the contact

information I have provided in this Consent. I understand that I will have 10 business

days from the date that the written notice is sent to me to respond, within which time I

may request the Court to declare this Consent voidable and return the child to me. I

further understand that the Court will make the final decision of whether or not the child

will be returned to me. If I do not make such request within 10 business days of the date

of the notice, then I expressly waive any other notice or service of process in any legal

proceeding for the adoption of the child.

10. That I expressly acknowledge that nothing in this Consent impairs the validity and

absolute finality of this Consent under any circumstance other than those described in

paragraph 9 of this Consent.

11. That I understand that I have a remaining duty and obligation to keep _______________

_________________________________________________________ (insert name and

address of the attorney for the specified person or persons) informed of my current

address or other preferred contact information until this adoption has been finalized. My

failure to do so may result in the termination of my parental rights and the child being

placed for adoption in another home.

12. That I do expressly waive any other notice or service of process in any of the legal

proceedings for the adoption of the child as long as the adoption proceedings by the

specified person or persons is pending.

13. That I have read and understand the above and I am signing it as my free and voluntary

act.

14. That I acknowledge that this Consent is valid even if the specified person or persons

separate or divorce or one of the specified persons dies prior to the entry of the final

judgment for adoption.

___________________________________ ____________________________________

Signature of Biological Parent Phone Number(s) of Biological Parent

___________________________________ ____________________________________

Address of Biological Parent Personal email(s) of Biological Parent

Dated this ______ day of __________________ 20 ______, at _________o’clock a.m. / p.m.

Final & Irrevocable Consent to Adoption-Non-DCFS

Rev. 04-01-16/p.3


JUDICIAL CIRCUIT


STATE OF _____________________________ ) CASE NO. ____________________________

)

)

COUNTY OF ___________________________ )

CERTIFICATE OF ACKNOWLEGEMENT OF CONSENT FINAL AND

IRREVOCABLE CONSENT TO ADOPTION BY A SPECIFIED PERSON OR

PERSONS: NON-DCFS CASE

I, ____________________________________________________________ (name of Judge or

other person), _____________________________________________________ (official title,

name and address), certify that ____________________________________________________

personally known to me to be the same person whose name is subscribed to the foregoing Final

and Irrevocable Consent for Adoption by a Specified Person or Persons, non-DCFS case,

appeared before me this day in person and acknowledged that (she) (he) signed and delivered the

Consent as (her) (his) free and voluntary act, for the specified purpose. I am further satisfied that,

before signing this Consent, _______________________________________________________

has read, or has had read to him/her, the Birth Parent Rights and Responsibilities-Private Form.

I have fully explained that by signing such Consent she/he is irrevocably relinquishing all

parental rights to such child and she/he has stated that such is her/his intention and desire.

__________________________________ ______________________________________

Date Judge

Seal of the Court



FORM (750 ILCS 50/10)




required to do so.








required to do so.


meet them.


















to do so.


















______________________________________

Initials

Consent to Adoption of Unborn Child/p.1

Rev. 04-01-16


JUDICIAL CIRCUIT


_________________________________ CASE NO. ______________________________

_________________________________

Petitioner

vs.

_________________________________

_________________________________

Defendant

CONSENT TO ADOPTION OF UNBORN CHILD I, ________________________________________________, state:

(name of father)

That I am the father of a child expected to be born on or about ________________________ to

_________________________________________________.

(name of mother)

That I reside at _________________________________________________________, County

of ___________________________________________ and State of ___________________________.


That I hereby enter my appearance in such adoption proceeding and waive service of summons

on me.

That I hereby acknowledge that I have been provided with a copy of the Birth Parent Rights and

Responsibilities-Private Form before signing this Consent, and that I have had time to read, or have had

read to me, this Form. I understand that if I do not receive any of the rights as described in this Form, it

shall not constitute a basis to revoke this Consent to Adoption of Unborn Child.

That I do hereby consent and agree to the adoption of such child, and that I have not previously

executed a Consent or Surrender with respect to such child.

That I wish to, and do understand that by signing this consent I do, irrevocably and permanently

give up all custody and other parental rights I have to such child, except that I have the right to revoke this

consent by giving written notice of my revocation not later than 72 hours after the birth of the child.

THAT I UNDERSTAND SUCH 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 SUCH CHILD.


Dated this ________ day of _________________________, 20_____.

_________________________________________

(Signature)


Rev. 04-01-16

STATE OF ILLINOIS )

) SS.

COUNTY OF DEKALB )

I, ____________________________________________________________________________, (name and official title)

do hereby certify that ______________________________________, personally known to me to be the

same person whose name is subscribed to the foregoing consent, appeared before me this day in person

and acknowledged that he signed and delivered such consent as his free and voluntary act, for the

specified purpose.

I have fully explained that by signing such consent he is irrevocably relinquishing all parental

rights to such child or adult and he has stated that such is his intention and desire.

In Witness Whereof, I have hereunto affixed my signature this ______ day of ______________,

20 _____.

STATE OF ILLINOIS )

) SS.

COUNTY OF DEKALB )


_____________________________________, personally known to me to be the same person whose

name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and

acknowledged that (she) (he) signed such certificate as (her) (his) free and voluntary act and that the

statements made in said certificate are true.

Given under my hand and notarial seal this ______ day of __________________, 20____.

(OFFICIAL SEAL) ______________________________ Notary Public


Rev. 04-01-16


FORM (750 ILCS 50/10)




required to do so.








required to do so.


meet them.


















Rev. 04-01-16


to do so.

















______________________________________

Initials

Surrender of Unborn Child for Adoption/p.1 Rev. 04-01-16


JUDICIAL CIRCUIT


_________________________________ CASE NO. __________________________

_________________________________

Petitioner

vs.

_________________________________

_________________________________

Defendant

SURRENDER OF UNBORN CHILD FOR PURPOSES OF ADOPTION I, _____________________________________________________, state:

(father)

That I am the father of a child expected to be born on or about ____________________________

to___________________________________________________________________________________.

(name of mother)

That I reside at _________________________________________________________________,

County of _______________________________ and State of __________________________________.


That I do hereby surrender and entrust the entire custody and control of such child to the

____________________________________________________________________________________, (Agency)

a (public) (licensed) child welfare agency with its principal office in the City of

___________________________, County of ______________________, and State of

___________________________________, for the purpose of enabling it to care for and supervise the

care of such child, to place such child for adoption and to consent to the legal adoption of such child, and

that I have not previously executed a consent or surrender with respect to such child.

That I hereby grant to said Agency full power and authority to place such child with any person

or persons it may in its sole discretion select to become the adopting parent or parents and to consent to

the legal adoption of such child by such person or persons; and to take any and all measures which, in the

judgment of said Agency, may be for the best interests of such child, including authorizing medical,

surgical and dental care and treatment including inoculation and anesthesia for such child.

That I wish to, and understand that by signing this surrender I do, irrevocably and permanently

give up all custody and other parental rights I have to such child.

Surrender of Unborn Child for Adoption/p.2 Rev. 04-01-16

THAT I UNDERSTAND I CANNOT UNDER ANY CIRCUMSTANCES, AFTER SIGNING THIS

SURRENDER, CHANGE MY MIND AND REVOKE OR CANCEL THIS SURRENDER OR OBTAIN OR

RECOVER CUSTODY OR ANY OTHER RIGHTS OVER SUCH CHILD, EXCEPT THAT I HAVE THE

RIGHT TO REVOKE THIS SURRENDER BY GIVING WRITTEN NOTICE OF MY REVOCATION NOT

LATER THAN 72 HOURS AFTER THE BIRTH OF SUCH CHILD.


Dated this ________ day of _________________________, 20_____.

________________________________

(Signature)

____________________________________

Witness

____________________________________

Date

STATE OF ILLINOIS )

) SS.

COUNTY OF DEKALB )

I, ___________________________________________________________________________________________, (name and official title)

do hereby certify that ___________________________________________, personally known to me to be the same

person whose name is subscribed to the foregoing Surrender, appeared before me this day in person and

acknowledged that he signed and delivered such Surrender as his free and voluntary act, for the specified purpose.

I have fully explained that by signing such consent he is irrevocably relinquishing all parental rights to such

child or adult and he has stated that such is his intention and desire.

In Witness Whereof, I have hereunto affixed my signature this ______ day of ____________________, 20

_____.

STATE OF ILLINOIS )

) SS.

COUNTY OF DEKALB )


_________________________________, personally known to me to be the same person whose name is subscribed

to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (she) (he)

signed such certificate as (her) (his) free and voluntary act and that the statements made in said certificate are true.

G iven under my hand and notarial seal this ______ day of ____________________________, 20____.

(OFFICIAL SEAL) _______________________________________

Notary Public

Adoption Notice

Rev. 04-01-16


JUDICIAL CIRCUIT


_______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

CASE NO. _______________________________

ADOPTION NOTICE

In the Matter of the Petition for Adoption of _______________________________________________, a

male/ female child, Adoption No.:________________________.

TO: _______________________________________________________________________________________

____________________________________________________________________________________________________

(whom it may concern or the named parent)

TAKE NOTICE that a Petition was filed in the Circuit Court of DeKalb County, Illinois, for the adoption of a child

named ________________________________________________________________.

NOW THEREFORE, unless you, _________________________________________________________________,

and all whom it may concern, file your Answer to the Petition in said suit or otherwise file your appearance therein, in the said

Circuit Court of DeKalb County, 133 West State Street, Room 203, in the City of Sycamore, Illinois, on or before the

____________ day of _____________________________, 20_____, a default may be entered against you at any time after

that day and a judgment entered in accordance with the prayer of said Petition.

DATED at Sycamore, Illinois, this __________ day of ___________________________, 20_____.

__________________________________________________

Clerk of the Circuit Court

Attorney for Petitioner(s):

Name: ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Telephone No.: ___________________________________________

To be published at least once in each week for three successive weeks, with the first publication being at least 30 days prior to the return date stated above.

Publisher: Please send __________ copies of this publication to the above-named Clerk as soon as possible.

Affidavit for Publication

Rev. 04-01-16


JUDICIAL CIRCUIT


_______________________________________________

_______________________________________________

Petitioner(s),

vs.

_______________________________________________

_______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

)

CASE NO. ___________________________________

AFFIDAVIT FOR PUBLICATION

Petition for Adoption of a Child named _______________________________________

___________________________________________________________________________________, being first duly sworn, says

he/she is (a) _________________________________________________________________________________ and further states:

1. That the Respondent (b) ________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

2. That the Respondent reside(s) (c) ________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________________________

__________________________________________________________

Subscribed and sworn to before me this ________ day of

__________________________, 20________________.

______________________________________________

Notary Public

(a) Insert name of “Petitioner” or “Attorney for Petitioner”

(b) Insert correct facts as set forth in Chap. 110, Par. 14, I.R.S.

(c) Insert address of non-resident Respondent when known.

Affidavit

Rev. 04-01-16


JUDICIAL CIRCUIT


IN RE:

ADOPTION OF _____________________________________

)

)

)

CASE NO.___________________________

AFFIDAVIT

__________________________________________________________ on oath, and under penalty of perjury, states:

1. That Affiant is involved in the adoption as:

a) Agency: _________________________________________

b) Natural parents of child sought to be adopted.

c) Petitioner.

d) Attorney.

e) Other.

2. Affiant has:

a) been given

b) been promised

c) received

d) paid

e) promised to pay

the following in connection with this adoption:

Hospital: $________

Physician:

$________

Medicine:

$________

Other Medical Expenses:

$________

Maternity Home:

$________

Agency Fee:

$________

Attorney’s Fees:

$________

Court Costs:

$________

Guardian ad Litem Fees:

$________

Other:

$________

___________________________________________

(Affiant)

Subscribed and sworn to before me on this date:

_____________________________________.

_____________________________________

Notary Public

Certificate of Mailing

Rev. 04-01-16


JUDICIAL CIRCUIT

DEKALB COUNTY, ILLINOIS __________________________________ ) CASE NO. ______________________________

)

_______________________________ ) Petitioner(s), )

vs. )

__________________________________ )

) Petition for the Adoption of a Child Named:

__________________________________ )

Respondent(s). ) _______________________________________

CERTIFICATE OF MAILING

I, ________________________________________ (Deputy) Clerk of the Circuit Court of the County of

DeKalb and State of Illinois, do hereby certify that on the __________ day of ________________________,

________, I deposited in the United States mail at ___________, Illinois, a true copy of the Publication Notice in

said cause hereto attached, enclosed in an envelope properly sealed, postage prepaid and correctly addressed, to

each of the following-named persons at the respective address shown opposite each name:

NAME RESIDENCE ADDRESS

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

I further certify that said mailing was made with ten (10) days of the publication of said notice.

WITNESS the hand of said Clerk and the seal of said Court

hereto affixed this date ________________________________. ___________________________________________________ (Clerk)

Order Appointing Guardian Ad Litem

Rev. 04-01-16


JUDICIAL CIRCUIT


In The Interest Of

______________________________, a minor

)

)

)

)

)

CASE NO. _________________________________

ORDER APPOINTING GUARDIAN AD LITEM

This cause now coming on to be heard upon the Petition of______________________________.

It appears to the Court that it is in the best interest of the minor to appoint a Guardian ad Litem.

THEREFORE, IT IS HEREBY ORDERED BY THIS COURT, that _____________________

________________________, is appointed Guardian ad Litem for the said minor _________________

____________________________ to make answer unto said Petition, to represent said minor in this

proceeding, to be and appear upon the hearing of said Petition in this Court, and defend the rights and

interests of said minor in said cause. That said Guardian ad Litem shall have the power and authority to

consent to the adoption of said child should such Guardian ad Litem see fit to do so.

Dated______________________, 20_____

___________________________________

Judge

Answer of Guardian Ad Litem

Rev. 04-01-16


JUDICIAL CIRCUIT


In The Interest Of

______________________________, a minor

)

)

)

)

)

CASE NO. _________________________

ANSWER OF GUARDIAN AD LITEM

______________________________________________________________________, a minor by

____________________________________________________, Guardian ad Litem, answers unto

said Petition say______ that ____________ is not advised of the matters and things in said Petition

contained, and neither admit nor deny them, and respectfully demand that said Petitioner______ be

strictly required to prove the allegations in said Petition.

Dated_________________________, 20_____

______________________________________

(Guardian Ad Litem)

Name: ______________________________________

Attorney for: ______________________________________

Address: ______________________________________

City, State, Zip: ______________________________________

Telephone: ______________________________________

Interim Order-Adoption / p.1

Rev. 04-01-16


JUDICIAL CIRCUIT


_________________________________ ) CASE NO. _______________________________

_________________________________ )

Petitioner(s), )

)

vs. )

__________________________________ )

__________________________________ )

Respondent(s).

INTERIM ORDER

The Petition of _____________________________________________________________, having been filed

herein on the____ day of _____________, 20_____, for the adoption of______________________________________,

a minor child;

And it appearing to the court that the child sought to be adopted herein is a minor, and that the court should

therefore appoint a Guardian ad Litem to represent the interests of said child in this proceeding;

IT IS THEREFORE ORDERED that _________________________________________________________,

a duly licensed attorney under the laws of the State of Illinois and a member of this bar, be and hereby is appointed as

Guardian ad Litem to represent the interests in this proceeding of _________________________________________,

the minor child sought to be adopted herein.

And it further appearing to the court that all of the other Respondent(s) to this cause are of full legal age and

under no legal disability, except _____________________________________________________________________

_______________________________________________________________________________________________,

who is/are: ______________________________________________________________________________________

_______________________________________________________________________________________________,

and that the court should therefore appoint a Guardian ad Litem to represent the interests in this proceeding of said

Respondent(s).

IT IS THEREFORE ORDERED that ________________________________________________________, a

duly licensed attorney under the laws of the State of Illinois, and a member of this bar, be and hereby is appointed as

Guardian ad Litem to represent the interests in this proceeding of said Respondent, _____________________________

_____________________________________________________________________________________________.

And said Petition now coming on for preliminary hearing as provided by Section 13 of the Illinois Adoption

Act, and the court being now fully advised in the premises, DOTH FIND:

Interim Order-Adoption / p.2

Rev. 04-01-16

1. That written consents to the adoption of said child by Petitioner(s) have been executed and filed herein by

the following named persons, and/or agency___________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

____________________________________________________________________________________________

that all of said consents have been executed according to law, and are valid and binding.

2. (a) That _________________________________________________________________________

is/are willing to accept and assume temporary custodial care of the child sought to be adopted herein, pending a final

determination of this cause; that such temporary custodial care is suitable and proper for the welfare of said child.

(b) That it is in the best interests of said child that the custodial rights of his/her parents be terminated,

and that said child be temporarily committed to the care and custody of some competent person or agency pending a

final determination of this cause; that _____________________________________________________________ is a

suitable, proper and competent person/agency, and that it will be for the welfare of said child that he/she be temporarily

committed to the care and custody of the said ________________________________________________________,

pending a final determination of this cause.

IT IS THEREFORE ORDERED, ADJUDGED and DECREED by the court as follows:

1. That the custodial rights of the parents of said child be and they are hereby terminated, and that said child

be and he/she is hereby declared to be a ward of this court.

2. That said child be and he/she is hereby committed to the temporary care and custody of

___________________________________________________________________, pending a final determination of

this cause.

3. _________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

____________________________________________________________________________________________

ENTERED this __________ day of _______________________________, 20_____.

____________________________________________________

Judge

Supplementary Interim Order

Rev. 04-01-16


JUDICIAL CIRCUIT


IN THE MATTER OF ) CASE NO. ____________________________

)

BABY (BOY / GIRL) )

)

_____________________________________ )

SUPPLEMENTARY INTERIM ORDER

In accordance with Interim Order entered herein on ____________________________________

and impounded,

IT IS HEREBY ORDERED that _________________________________________ (institution)

deliver custody of the above-entitled child to _______________________________________________,

Child Welfare Worker of DeKalb County, Illinois, for temporary custody placement by her/him in

accordance with above Interim Order.

IT IS FURTHER ORDERED that the Clerk of the Circuit Court be authorized to make a certified

copy of this Supplemental Interim Order only.

DATED: ______________________________

_____________________________________________

Judge

Order for Investigation

Rev. 04-01-16


JUDICIAL CIRCUIT


__________________________________________________

__________________________________________________

Petitioner(s),

vs.

__________________________________________________

__________________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

)

)

CASE NO. _____________________________

ORDER FOR INVESTIGATION

IT IS HEREBY ORDERED BY THE COURT that ______________________________________, be,

and hereby is, specifically designated to investigate, accurately, fully and promptly the allegations contained in

the Petition heretofore filed, and also the character, reputation and general standing in

______________________________________________ community of the Petitioner(s), the religious faith of

the Petitioner(s), and if ascertainable, of the child sought to be adopted, and also whether the Petitioner(s) is/are a

proper person(s) to adopt the child named in the Petition on file herein and whether the said child is a proper

subject of adoption.

IT IS FURTHER ORDERED BY THE COURT THAT ___________________________________,

reduce to writing the information obtained as the result of such investigation and present the same to the Court on

or before the return day designated in the Summons issued in this proceeding.

IT IS FURTHER ORDERED BY THE COURT that the costs of such investigation be charged to

____________________________________________________.

ENTERED this _____ day of ____________________, 20_____.

_______________________________________

Judge

Decree of Adoption/p.1

Rev. 04-01-16


JUDICIAL CIRCUIT


______________________________________________

______________________________________________

Petitioner(s),

vs.

______________________________________________

______________________________________________

Respondent(s).

)

)

)

)

)

)

)

)

)

)

CASE NO. ______________________________

DECREE OF ADOPTION

This cause coming on to be heard upon the verified Petition of ____________________________________ for

the adoption of ___________________________________________________, hereinafter sometimes referred

to as the “child,” and ____________________________________________________________ the court being

fully advised in the premises finds as follows:

(1) Respondent(s) is/are all the person(s) entitled to be notified of the within proceeding and have been

so notified in the following manner: ____________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(2) Valid properly acknowledged consents to the adoption of said child and have been filed as required

by an Act of the General Assembly of the State of Illinois entitled “An Act in Relation to the Adoption of

Persons and to Repeal an Act Therein Named,” approved July 17, 1959, as follows:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

(2-a) Consents to the adoption of said child have not been filed for the following reasons:

__________________________________________________________________________________________

__________________________________________________________________________________________

(3) It appearing to the court that ________________________________________________________

Respondent(s) are in the military service of the United States, or that their military status is unknown,

thereupon the court appointed ________________________________________________________________,

attorney of record for such Respondent(s) or those who may be in the military service of the United States.


Rev. 04-01-16

(4) The court heretofore appointed _____________________________________________________

Guardian ad Litem of said child.

(5) On ___________________________, 20_____, the court appointed ________________________

to make the investigation required to be made under the provisions of said Act as to the allegations contained in

said Petition, the character, reputation and general standing in the community of the Petitioner(s), the religious

faith of the Petitioner(s) and, if ascertainable, of said child, whether Petitioner(s) are proper persons to adopt

said child and whether said child is a proper subject of adoption. The said ____________________________

______________________ has made a report of said investigation to the court which report the court approves.

(6) On ___________________________, 20_____, which was at a time as soon as practical after the

filing of said Petition, the court held a hearing for the purpose of complying with Section 13 of said Act and, as

shown by the records kept by the Clerk of this Court, the hearing thereof and the order or orders entered by the

court complied with said Section 13.

(7) Said child not being a related child, one of the orders referred to in Par. 6 hereof was an Interim

Order entered ___________________________, 20_____, vesting temporary care, custody and control of the

child to the Petitioner(s).

(8) Upon this ___________ day of _______________________, 20_____, Petitioner(s) have applied

to this court for the entry of a Decree of Adoption. Notice of said application was served by Petitioner(s) upon

the following agency or person and at the following time and manner: _________________________________

__________________________________________________________________________________________

(9) A hearing was held upon said application on __________________________________________,

20_____, at which Petitioner(s) and the child appeared.

(9-A) A hearing was held upon said application on _____________________________, 20______, at

which hearing __________________________________________________________________ did not appear

because such appearance was waived by the court for good cause shown which was as follows:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

(10) The court is satisfied from the report referred to in par. 5 hereof and from the evidence introduced

at said hearing that the adoption is for the welfare of said child and that the consents for adoption referred to in

Par. 2 hereof are valid and have been filed by all persons required to do so under the provisions of said Act in

order for the court to enter this Decree.

(10-A) The court is satisfied from the report referred to in par. 5 hereof and from the evidence

introduced at said hearing that the adoption is in the best welfare of said child and that no consent for adoption

is required as provided in Section 8 of said Act for the reasons given in par. 2-A hereof.


Rev. 04-01-16

(11) The evidence given at the aforesaid hearing sustained the allegations of said petition and said

allegations are true.

(12) The said child was born on __________________________________________, 20_____, in the

County of _________________________, State of __________________________. Petitioner(s) reside in the

County of _________________________, State of ___________________. The parents of said child reside as

follows:___________________________________________________________________________________

Petitioner(s) have satisfied all the requirements of said Act to entitle them to adopt said child and are subject to

the jurisdiction of the court in this proceeding under the provisions of the Act. Said child is subject to the

jurisdiction of this court in this proceeding under the provisions of said Act and is entitled to be adopted by

Petitioner(s).

(13) No consent or surrender for adoption was taken until the passage of seventy-two hours after the

birth of the child.

(14) It will be for the welfare of the child to waive the waiting period of six months provided in Section

14 of the Act and grant a Decree of Adoption.

(15) _______________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________________________________________________________.

NOW, THEREFORE, IT IS ORDERED, ADJUDGED AND DECREED as follows:

(a) The said ________________________________________________________________________

be and hereby is adopted by ___________________________________________________________________

and said __________________________________________________________________________________

be and hereby is the child of __________________________________________________________________.

(b) The name of said child be and hereby is changed to _____________________________________.

(c) The natural parents of said child be and are hereby deprived of all legal rights with respect to said

child and said child be freed from all obligations whatsoever to said natural parents.

Dated ____________________________________, 20_____.

____________________________________________

Judge

in the circuit court for the twenty-third judicial...

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