You have the right to have these instructions and the consent form translated into a language that you understand. If you cannot read or understand English, you should not sign the consent form. You should have this form translated for you into a language you do understand. The translated consent form is the one you should read and decide whether or not to sign. Any translation must have an affidavit attached in which the translator states that it is a true and accurate translation of this document.

You have the right to speak with a lawyer before you decide whether or not to consent.

You should not sign the consent form without a lawyer if you are under 18 years old or have a disability that makes it difficult for you to understand this document. If you are under 18 years old or have a disability that makes it difficult for you to understand this document, you are required to have a lawyer review the form with you before you can consent to the adoption.

Even if you are not required to have a lawyer, you have the right to speak with a lawyer you choose before you decide whether to consent.

You have the right to receive adoption counseling and guidance. If you want adoption counseling or guidance, you should not complete this consent form until after you have gotten adoption counseling or guidance.

IF YOU SIGN THE CONSENT FORM, YOU WILL NOT BE GIVING UP ANY RIGHTS OR RESPONSIBILITIES RELATING TO THE CHILD.

If you sign the consent form and then change your mind and no longer want to consent, you have the right to revoke (cancel) the consent within 30 days after the date that you sign the consent form. The only way that you can revoke this consent is by giving a signed written revocation statement with the name, sex, and date of birth of the child (if you know it) to:

Adoption Clerk, Circuit Court for __________, at __________ Address).

The revocation must be sent to the court, not to the lawyers or the people adopting the child. You may deliver your written revocation of consent in person or by mail. If it is not received by the Adoption Clerk’s office within 30 days after the date you signed the consent form, it will be too late, and you will not be able to withdraw the consent or stop the adoption from being granted.

If you sign this consent form, and then revoke your consent, and then decide to consent to the adoption again, you will not be able to revoke your second consent if you give your second consent in court within one year of your revocation of this consent.

A petition for adoption has been or will be filed in the Circuit Court for __________. If you sign the consent form, your written consent will also be filed in the court. You have the right to be notified when the petition is filed, when any hearings are held before the adoption is granted, and if and when the adoption is granted. Any notices will be sent to the address given by you on the consent form, unless you write to the Adoption Clerk at __________ (court’s address) and give the clerk your new address. You may waive (give up) your right to notice if you wish to do so. Even if you give up your right to notice, someone from the court may contact you if further information is needed.

Under Maryland law, you are not allowed to charge or receive money or compensation of any kind for the placement for adoption of your child or for your agreement to the adoptive parent having custody of your child, except for (1) reasonable and customary charges or fees for adoption counseling, hospital, legal, or medical services, (2) reasonable expenses for transportation for medical care associated with the pregnancy or birth of the child, (3) reasonable expenses for food, clothing, and shelter for a birth mother if, on written advice of a physician, the birth mother is unable to work or otherwise support herself because of medical reasons associated with the pregnancy or birth of the child, and (4) reasonable expenses associated with any required court appearance relating to the adoption, including transportation, food, and lodging expenses.

When your child is at least 21 years old, your child, your child’s other parent, or you may apply to the Secretary of the Maryland Department of Health for access to certain birth and adoption records. If you do not want information about you to be disclosed (given) to that person, you have the right to prevent disclosure by filing a disclosure veto. Attached to this document is a copy of the form that you may use if you want to file a disclosure veto.

When your child is at least 21 years old, your child, your child’s other parent or siblings, or you may apply to the Director of the Social Services Administration of the Maryland Department of Human Services for adoption search, contact, and reunion services.

If you or your child are members of or are eligible for membership in an Indian tribe, as defined by federal law, you have special legal rights under the Indian Child Welfare Act. You should not sign this consent form if you believe this may apply to you. You should tell the person requesting the consent or the court that you believe that your child’s case should be handled under the Indian Child Welfare Act.

If you decide to complete and sign the consent form, you must have a witness present when you sign it. The witness must be someone 18 or older and should not be the child or the child’s other parent. You must complete and sign the form with a pen and print or type in your name, address, and telephone number. The witness also must sign the form and print or type in the witness’ name, address, and telephone number in the blanks on the last page.

If you have a post-adoption agreement, you must attach a copy to the signed consent form.

You have the right to receive a copy of the signed consent form.

STOP HERE IF YOU DID NOT UNDERSTAND SOMETHING YOU HAVE READ OR IF YOU WANT TO SPEAK WITH A LAWYER OR GET ADOPTION COUNSELING BEFORE YOU DECIDE IF YOU WANT TO SIGN THE CONSENT FORM.

If you wish to sign the consent form, you must also sign here to verify that you read these instructions and understand them:

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

[ ] I already have spoken with a lawyer whose name and telephone number are __________. I have read the instructions at the front of this form, and I am ready to consent to the adoption.

OR

[ ] I am at least 18 years old and am able to understand this document. I have read the instructions at the front of this form, and I do not want to speak with a lawyer before I consent to the adoption.

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

[ ] I have already spoken with a counselor. I have read the instructions at the front of this form, and I am ready to consent to the adoption.

OR

[ ] I do not want to speak with a counselor. I have read the instructions at the front of this form, and I am ready to consent to the adoption.

I voluntarily and of my own free will consent to the adoption of my child, __________ , by __________. I also agree that such person(s) shall have temporary custody of the child until the completion of the adoption.

Check one of the following:

[ ] I give up (waive) the right to any further notice of the adoption case.

OR

[ ] I want to be notified when the adoption case is filed, of any hearings, and if and when my child is adopted.

I understand that if I change my mind and no longer consent to the adoption, I have the right to revoke this consent within 30 days after the date that I signed this consent form I understand that the only way that I can revoke this consent is by giving a signed written revocation statement to the Adoption Clerk, Circuit Court for __________ at _____________________________________________________________.

I UNDERSTAND THAT IF I SIGN THIS CONSENT FORM, I WILL NOT BE GIVING UP ANY RIGHTS AND RESPONSIBILITIES RELATING TO THE CHILD.

I have read carefully and understand the instructions at the front of this consent form. I am signing this consent form voluntarily and of my own free will.

I solemnly affirm under the penalties of perjury that the contents of this consent form are true to the best of my knowledge, information, and belief.