General Consent to Adoption

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FAMILY COURTGENERAL CONSENT TO ADOPTION CASE NUMBERFIRST CIRCUITOF []MOTHER[]FATHER FC-A No.STATE OF HAWAI‘I []OTHER:NAME OF PERSON OR AGENCY AUTHORIZED TO SELECT AND APPROVE ADOPTIVEPARENTS: Position Title:INFORMATION REGARDING THE CHILD(REN)’S PARENTSFATHERMOTHERFull Legal NameStreet AddressCity, State, Zip CodeTelephone NumberSocial SecurityDate of BirthRacial ExtractionINFORMATION REGARDING THE CHILD(REN)’S PARENTSLEGAL ONLY FATHEROTHER LEGAL PARENTFull Legal NameStreet AddressCity, State, Zip CodeTelephone NumberSocial SecurityDate of BirthRacial ExtractionIn accordance with the Americans with Disabilities Act, as amended, and other applicablestate and federal laws, if you require accommodation for a disability, please contact theADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308,or via email at [email protected] at least ten (10) working days prior to your hearingor appointment date.Please call the Family Court Service Center at 954-8290 if you have any questionsregarding forms or procedures.COURT USE ONLYHo‘okele/FC Adm 2/10/16PAGE  1  OF  4  PAGESGENERAL CONSENT TO ADOPTION

FAMILY COURTGENERAL CONSENT TO ADOPTION CASE NUMBERFIRST CIRCUITOF []MOTHER[]FATHER FC-A No.STATE OF HAWAI‘I []OTHER:INFORMATION REGARDING THE CHILDFull Legal NameSex[] MALE[]FEMALEDate of BirthPlace of BirthINFORMATION REGARDING THE CHILDFull Legal NameSex[] MALE[]FEMALEDate of BirthPlace of BirthINFORMATION REGARDING THE CHILDFull Legal NameSex[] MALE[]FEMALEDate of BirthPlace of BirthHo‘okele/FC Adm 2/10/16PAGE  2  OF  4  PAGESGENERAL CONSENT TO ADOPTION

FAMILY COURTGENERAL CONSENT TO ADOPTION CASE NUMBERFIRST CIRCUITOF []MOTHER[]FATHER FC-A No.STATE OF HAWAI‘I []OTHER:The undersigned being first duly sworn on oath, deposes and says that:1.I am the parent of the above-identified child(ren).2.I hereby consent to the placement of the above-identified child(ren) for adoption and to the legaladoption of said above-identified child(ren) by adoptive parent(s) selected and approved by theperson or agency named on Page 1 of this General Consent to Adoption.3.I understand that after I sign this General Consent to Adoption and after a Decree of Adoption isfiled by the Court,  the legal name of the child(ren) may be changed and all of my parental rightsas well as responsibilities for said child(ren) will be terminated.4.I further understand that after I sign this General Consent to Adoption and after a Decree ofAdoption is filed by the Court, I will no longer have any legal right or responsibility to provide care,guidance, and control for said child(ren).5.I further understand that by signing this General Consent to Adoption and after a Decree ofAdoption is filed by the Court, I will no longer have any legal right to visit with said child(ren).6.I declare that no representations have been made to me, by anyone, which would serve in any wayto limit the complete surrender of all my parental rights intended by this consent or to limit theparental rights to be acquired by the proposed adoptive parent(s).7.I further understand that after this consent has been signed by me, the consent will be valid andbinding, even though I may be under the age of 18 years.8.I further understand that after the child(ren) has/have started to reside with the above-namedadoptive parent(s) or after this consent has been filed with the Court in an adoption proceeding bythe proposed adoptive parent(s), this consent may not be withdrawn or repudiated without thewritten order of a judge who has jurisdiction in adoption proceedings, based upon written finding,supported by proof to be submitted by me, that the withdrawal of my consent would be in the bestinterest of the child(ren).9.No one has forced or coerced me to sign this General Consent to Adoption.10.No one has made any promises whatsoever to me in return for signing this General Consent toAdoption.11.I have not been offered nor have I accepted any reward or money in exchange for signing thisGeneral Consent to Adoption.12.I waive further notice of any proceedings regarding the adoption of the child(ren), however if theadoption fails to be granted, I want to be given notice.Ho‘okele/FC Adm 2/10/16PAGE  3  OF  4  PAGESGENERAL CONSENT TO ADOPTION

FAMILY COURTGENERAL CONSENT TO ADOPTION CASE NUMBERFIRST CIRCUITOF []MOTHER[]FATHER FC-A No.STATE OF HAWAI‘I []OTHER:CONFIDENTIALITY PURSUANT TO HRS § 578-15 (continued)13.I have been advised of the requirements of Section 578-15 of the Hawai‘i Revised Statutesregarding confidentiality of the court’s adoption file.14.When my child become 18 years old, my child or the adoptive parents can request, in writing, to seethe court’s file regarding this adoption.15.If I do not want the Family Court to reveal my identity to my child or the adoptive parents, I must filean affidavit requesting confidentiality with the Family Court (on this island that the adoptionoccurred) within ninety (90) calendar days before my child(ren)’s 18th
 birthday. This affidavit is goodfor ten (10) years.16.After that, I can file an affidavit every ten (10) years or I can file an affidavit to keep my identityconfidential for the rest of my life.17.All affidavits must be filed within ninety (90) days prior to the expiration of the previous affidavit.18.After my child(ren) reach/reaches 18 years old, I can request to see the court’s adoption file, too,but my child(ren) has/have the same rights as I do to keep the file confidential.19.My decision to keep my information confidential or not applies to only me and does not apply to theother natural parent.20.I can agree to open up the adoption file at any time and my child(ren) can, too, after turning 18years old.21.It will be my responsibility to keep the Family Court informed of my current address if I wantdisclosure to be made.22.The Family Court has no responsibility to notify the child(ren), adoptive parent(s) or the naturalparent(s) of any deadlines or expiration dates.Date Signature of ParentOn this day,, in the First Circuit, State of Hawai‘i, before mepersonally appeared, who is known to me to be the personnamed in and who executed the foregoing four page document, entitled “General Consentto Adoption of Mother/Father/Other” and who subscribed and acknowledged that said consentwas read, understood, and executed as the free act and deed of said person.Notary Public’s Signature:Date:Print Notary Public’s Name:My commission expires:SEALHo‘okele/FC Adm 2/10/16PAGE  4  OF  4  PAGESGENERAL CONSENT TO ADOPTION