Affidavit by Attorney as to Consent of __________ (parent) to Guardianship with the Right to Consent to Adoption (?Guardianship?) by __________ (agency) of __________ (child)
[ ] The parent is not disabled or is disabled but the disability does not affect the parent’s ability to understand the meaning of the consent to guardianship.
OR
[ ] The parent is a minor or has a disability that could affect the parent’s ability to understand the meaning of the consent to guardianship. The disability is __________. Despite the parent’s age or disability, I believe that the parent understood the meaning of consenting to guardianship. The following additional steps were taken to ensure that the parent understood the meaning of the consent form prior to signing it: __________.
Check one of the following:
[ ] a family approved by the agency.
OR
[ ] __________ (name by which parent knows adoptive parent).
I solemnly affirm under the penalties of perjury that the contents of this affidavit are true to the best of my knowledge, information, and belief.
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(Date) |
(Signature) |
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(Printed Name) |
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(Address) |
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(City, State, Zip Code) |
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(Telephone Number) |