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Consent to Stepparent Adoption (from Parent Giving Up Child)

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Page 	1 of 	3 	
P-415 (	5/17	)(cs	) 	AS 25.23.060	-.070	 	
ADOPTION CONSENT	 (PARENT	/SPOUSE/GUARDIAN	) 	Adoption Rule 9	 	
 	
IN  THE  SUPERIOR  COURT  FOR  THE  STATE  OF  ALASKA	 	
 	AT 	 	 	
 
In the matter of the adoption of	 	) 	
 	) 	
 	) 	
 	 	) 	
 	(child's name after adoption)	 	) 	
 	 	) 	
DOB: 	 	, A Minor Child,	 	) 	
 	) 	
By 	 	, 	) 	CASE NO. 	 	 	
 	Petitioner.	 	) 	
 	) 	ADOPTION CONSENT	 	
 	 	(PARENT/SPOUSE/GUARD	IAN)	 	
 
1. 	Name of individual signing consent to adoption: 	 	 	
 	 	
2. 	Child’s name after adoption: 	 	 	
 
3. 	Relationship to child: 	 	 	
 	
4. 	I  understand  that  prior  to  signing  this  consent  I  have  the  right  to  consult  with  an 
attorney  of  my  choice,  at  my  expense.    I  also  understand  that  if  I 	do  not	 sign  the 	
consent	, but	 the 	person(s)  seeking  to  adopt  the  child  proceeds  with  filing  the 	adoption 	
petition	 anyway	, I may be eligible 	to request	 a court	-appointed attorney.	 	
 	
5. 	I consent to the adoption of the above	-named child by the 	person(	s) filing the adoption 	
petition	. 	
 	
6. 	 I  understand  that  by  signing  this  consent,  I  am  giving  up  all  my  rights  to  the  care, 	
custody  and  control  of  the  child,  and  that  I  am  giving  up  these  rights  permanently.    I 
will  also  be 	permanently	 relieved  of  all  responsibility  for  the  child  after  the  decree  of 	
adoption  is  signed.	  Except  as  stated  in  paragraph	 7 below  concerning  inheritance  and 	
visitation 	privileges	, I will no longer have any legal relationship to the child.	 	
[NOTE: This box must b	e checked unless this is a stepparent adoption.	] 	
 	
7. 	Visitation	 Privileges	. 	
 	I do not want to keep any visitation 	privileges	 after the adoption is granted.	 	
 	I r	equest that the court grant	 	 me	 	 my relat	ive 	 	 	
 	visitation	 privileges	 with  the  child 	at 	the  discretion  of  the 	adoptive  parent	(s), 	
according to the best interests of the child.	 	
 	 	I request that the court grant	 	 me	 	 my relat	ive 	 	 	
 	the  following  visitation	 privileges 	with  the  child:    (Describe  visitation  agreement, 	
including  times,  places,  who  pay	s  for  transportation,  etc.	  Attach  any  visitation 	
agreement if applicable.	)

Page 	2 of 	3 	
P-415 (	5/17	)(cs	) 	AS 25.23.060	-.070	 	
ADOPTION CONSENT	 (PARENT	/SPOUSE/GUARDIAN	) 	Adoption Rule 9	 	
 
8. 	The child	 	 	 is 	 	 is not 	 a member of an Indian tribe	; or eligible for such 	
membership	 and I, or the other biological parent, am a m	ember of an Indian tribe	. 	
 	
9. 	I  understand  I  have  a 	limited  right  to  withdraw  my  consent.    I  understand  that  my 	
consent  cannot  be  withdrawn  after  the  judge  signs  the  decree  of  adoption.    However, 
before the adoption decree is signed, I can withdraw my consent	 as follows:	 	
 
 	a. 	For a Non	-Indian Child: 	 	
 	 	 	
 	 	Within 10 days after I sign this form, I can deliver written notice	 of withdrawal	 to 	
the  court  at  the  address  in  paragraph 	10	 or  to  the  person  who  obtained  my 	
consent.  This written notice must be delivered or postmarked by the tenth day	, 	
and  I  must  keep  a  copy  of  that  notice 	of  withdrawal 	and  record  the  date  it  was 	
delivered or postmarked.	 	
 	
 	After the above 10	-day period, if th	e adoption 	decree has not been signed, I can 	
file a request to withdraw with the court, which the court may or may not grant.  
My request will be granted only if the court finds that it is in the best interests of 
the  child  after  both  the 	person  seeking  to	 adopt 	and  I  are  given  notice  and  an 	
opportunity to be heard.	 	
 	
 	b. 	 	For an Indian Child	 	
 	
At  any  time  before  the  signing  of  the  decree  of  adoption,  I  can  deliver  written 
notice	 of withdrawal 	to the court at the address in paragraph 	10	 or to the person 	
who obtained my consent.  This written notice  must be delivered or postmarked 
by  the 	last  day  of  this  time  period	,  and  I  must  keep  a  copy  of	 that  notice  and 	
record the date it was delivered or postmarked	. 	
 
10.	 	I understand that the adoption p	etition will be filed in the Superior Court at:	 	
 	Court Address: 	 	 	
 	Co	urt Telephone Number: 	 	 	
[NOTE: 	You can find the location and court telephone number here: 	http://www.courts.	
alaska.gov/courtdir/index.htm	] 	
 
11.	 	I 	 am	    	 am 	not	 	a m	inor.  My date of birth is 	 	. 	
 
12.	 	I have received a copy of this consent (or will receive one after it is signed).	 	
 
13.	 	I 	 do	   	 do not	 	want	 to 	receive	 notice  of  the  date  and  time  of  the  adoption 	
hearing.

Page 	3 of 	3 	
P-415 (	5/17	)(cs	) 	AS 25.23.060	-.070	 	
ADOPTION CONSENT	 (PARENT	/SPOUSE/GUARDIAN	) 	Adoption Rule 9	 	
 
I state on oath or 	affirm that I have read this consent form and believe all statements made in 	
it are true.  I am 	signing this consent freely and voluntarily.	 	
 
Note: This consent must be signed in a hearing in the presence of a judge when the 
consenting 	person	 is the  parent  of  an  Indian  child  or  the  consenting 	person	 is  a 	
minor.	 	
 
 	 	 	 	
 	Date	 	Signature of 	Person	 Giving Consent	 	
 	 	 	
 	Mailing Address	 	
 	 	 	
 	City	 	State	 	Zip	 	
 	 	 	
 	Daytime Phone	 	
 	______________________________________	  	 	 	 	 	 	
 	Email Address	 	
 
 
 	
ACKNOWLEDGEMENT & OATH	 	
On 	 	,  	 personally appeared 	 	
 	(date)	 	(name)	 	
before me in 	 	,  Alaska,  signed  the  above  consent  to 	
adoption, certified under oath or affirmation that he/she has read it and believes its contents to 
be  true,  and  acknowledged  that  he/she  signed  the  consent  freely  and  voluntarily  for  the 
purposes stated therein.	 	
 
(SEAL)	 	 	 	
 	Clerk  of  Court,  Notary  Public  or 	other  person 	
authorized to administer oaths.	 	
 	My commission expires:
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