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ity, State, Zip

Name

ddress

hone

In the District Court of Utah

__________ Judicial District ________________ County

Court Address ______________________________________________________

In the Matter of the Adoption of

Birth Mother’s Consent to Adoption
and Waiver of Rights

_____________________________________
(adoptee’s name)

_______________________________
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
before a person appointed by that judge. If you sign before a judge's appointee,
your signature must also be notarized or witnessed by two persons who are not
members of your immediate family.

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 the adoptee be
adopted.

Birth Mother’s Consent to Adoption and Waiver
of Rights

Approved Board of District Court Judges September 14, 2011
Revised November 26, 2019

Page 1 of 4

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.

I make this statement free from duress.

I am the adoptee’s birth mother, and I have the mental capacity to give consent.

I understand that by signing this Consent to Adoption and Waiver of Rights that I
am giving up all of my rights and responsibilities as parent of my child, including,
but not limited to:



the right to visit my child;

the right to provide my child with personal guidance and care;

the right to participate in decisions about my child’s health, education, welfare
and moral climate;

the right to act on my child’s behalf; and

the right to inherit from my child and the right of my child to inherit from me.

I understand that if my child is adopted, I will not have any parental rights or
responsibilities for my child.

I understand that if my child is adopted, the adopting parent will be known as my
child’s parent and my child will be known the adopting parent’s child. I
understand that my child may take the adopting parent’s family name.

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.

Understanding all of this, I voluntarily consent that my child be adopted.

Date

Printed name of the birth mother

Signature ►

Birth Mother’s Consent to Adoption and Waiver
of Rights

Approved Board of District Court Judges September 14, 2011
Revised November 26, 2019

Page 2 of 4



Option 1. Birth mother’s signature witnessed by judge.

On this date, I certify that _________________________________________________________ (name)
who is known to me or who presented satisfactory identification, in the form of
______________________________________________________ (form of identification), has, while in my
presence and while under oath or affirmation, voluntarily signed this document and declared that it is true.

Signature ►

Printed name of judge

Option 2. Birth mother’s signature witnessed by judge’s appointee and notary public.

Signature ►

Printed name of judge’s appointee

Printed name of notary public

Signature ►

Notary Seal

n this date, I certify that _________________________________________________________ (name)

who is known to me or who presented satisfactory identification, in the form of
______________________________________________________ (form of identification), has, while in my
presence and while under oath or affirmation, voluntarily signed this document and declared that it is true.

Birth Mother’s Consent to Adoption and Waiver
of Rights

Approved Board of District Court Judges September 14, 2011
Revised November 26, 2019

Page 3 of 4

Date

Option 3. Birth mother’s signature witnessed by judge’s appointee and two witnesses.

On this date, we certify that _________________________________________________________
(name) who is known to us or who presented satisfactory identification, in the form of
______________________________________________________ (form of identification), has, while in
our presence and while under oath or affirmation, voluntarily signed this document and declared that it is
true.

Signature ►

Printed name of judge’s appointee

Signature ►

Printed name of first witness

Signature ►

Printed name of second witness

Birth Mother’s Consent to Adoption and Waiver
of Rights

Approved Board of District Court Judges September 14, 2011
Revised November 26, 2019

Page 4 of 4

Date

Birth Mother’s Consent to Adoption and Waiver of Rights

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 4
Fields(s): 124
Average fields per page: 31
Reading Level: Grade 12
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Birth Mother’s Consent to Adoption and Waiver of Rights

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02