Adoptees Consent to Adoption and Waiver of Rights

If a person who is being adopted in the State of Utah wants to demonstrate his consent to that adoption, this form has to be used.

Extracted Text for Proper Search

Adoptee’s Consent to Adoption and Waiver of 
Rights Approved Board of District Court Judges December 17, 2010 
Revised April 8, 2015 Page 1 of 3 
   
This is a private record.
My Name 
 
Address 
 
City, State, Zip 
 
Phone 
 
Email 
 
In the District Court of Utah 
__________ Judicial District ________________ County 
Court Address ______________________________________________________ 
In the Matter of the Adoption of 
_____________________________________
(adoptee’s name) 	
Adoptee’s Consent to Adoption and 
Waiver of Rights 
Case Number ___________________ 
Judge  _________________________ 
Commissioner ___________________ 	
Do not sign this document without reading it. Do not sign it unless everything 
stated is true and correct. Sign it only before a judge of the Utah district court or 
the Utah juvenile court or a notary public or two witnesses appointed by a judge 
of those courts. If you have any questions, talk with an attorney. 
  You have the right to be notified of hearings and to be served with papers in this 
matter. You have the right to intervene and oppose the adoption. By signing this 
document you are giving up these rights and consenting that you be adopted. 
  If you agree with the adoption, complete this form, sign it, and return it to the 
Petitioner. 
  If you want to intervene and oppose the adoption, file a motion to intervene with this 
court within 30 days after the Notice of Petition to Adopt was served on you. 
(1)  I make this statement free from duress.

Adoptee’s Consent to Adoption and Waiver of 
Rights Approved Board of District Court Judges December 17, 2010 
Revised April 8, 2015 Page 2 of 3 
  (2)  I am the adoptee. I am over the age of 12, and I have the mental capacity to give 
consent. 
(3)  I understand that if I am adopted, my non-custodial parent will not have any 
parental rights or responsibilities for me. 
(4)  I understand that if I am adopted, my custodial parent will continue to have full 
parental rights and responsibilities for me. 
(5)  I understand that if I am adopted, the adopting parent will be known as my parent 
and I will be known as his or her child. I understand that I may take his or her 
family name. 
(6)  Understanding all of this, I voluntarily waive my right to be notified of hearings 
and served with papers in this matter, and I voluntarily waive my right to 
intervene in this matter. 
(7)  Understanding all of this, I voluntarily consent to be adopted. 
 	
Sign here ►
Date 
Typed or Printed Name of Adoptee	
 
Option 1. Adoptee’s signature witnessed by judge. 
I certify that __________________________, who is known to me or who presented satisfactory 
identification, has, while in my presence and while under oath or affirmation, voluntarily signed this 
document and declared that it is true. To the best of my information and belief, the person has read and 
understands the consent and has signed it freely and voluntarily. 
 Sign here ► 
Date 	
Typed or printed name of judge

Adoptee’s Consent to Adoption and Waiver of 
Rights Approved Board of District Court Judges December 17, 2010 
Revised April 8, 2015 Page 3 of 3 
 
Option 2. Adoptee’s signature witnessed by judge’s appointee and notary public	. 
I certify that __________________________, who is known to me or who presented satisfactory 
identification, has, while in my presence, voluntarily signed this document and declared that it is true.	
 To 
the best of my information and belief, the person has read and understands the consent and has signed it 
freely and voluntarily. 	
 Sign here ► 
Date 	
Typed or printed name of judge’s appointee 	 	
 
I certify that __________________________, who is known to me or who presented satisfactory 
identification, has, while in my presence and while under oath or affirmation, voluntarily signed this 
document and declared that it is true.	
 To the best of my information and belief, the person has read and 
understands the consent and has signed it freely and voluntarily. 
 Sign here ► 
Date 	
Typed or printed name of notary public 	 	
 	
Notary Seal 	 	
Option 3. Adoptee’s signature witnessed by judge’s appointee and two witnesses. 
We certify that __________________________, who is known to us or who presented satisfactory 
identification, has, while in our presence, voluntarily signed this document and declared that it is true.	
 To 
the best of our information and belief, the person has read and understands the consent and has signed it 
freely and voluntarily. 	
 Sign here ► 
Date 	
Typed or printed name of judge’s appointee 	 	
 Sign here ► 
Date 	
Typed or printed name of first witness 	 	
 Sign here ► 
Date 	
Typed or printed name of second witness