Check your email. You will receive information and 
documents at this email address.  

ity, State, Zip 

 
Name 

ddress 

  A

  C

  P

hone 

 
Email 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of the Adoption of 

_____________________________________ 
(adoptee’s name) 

Non-custodial Father’s Consent to 
Adoption and Waiver of Rights 

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 notary public or a court clerk. 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. 

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 non-custodial father, and I have the mental capacity to give 
consent. 

Non-custodial Parent’s Consent to Adoption and 
Waiver of Rights 

Approved Board of District Court Judges December 17, 2010 
Revised November 26, 2019 

Page 1 of 2 

 

 

1. 

2. 

 

3. 

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. 

7. 

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

Signature ► 

Printed Name 

 

 

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. 

Printed name (Court Clerk or Notary Public) 

Signature ► 

Notary Seal 

 

 

 

Non-custodial Parent’s Consent to Adoption and 
Waiver of Rights 

Approved Board of District Court Judges December 17, 2010 
Revised November 26, 2019 

Page 2 of 2 

4. 

5. 

6. 

Date 

 
Date