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. If you are unable to afford a lawyer, you may be eligible for a lawyer through the Office of the Public Defender. You should contact the Office of the Public Defender, and ask for a lawyer to represent you in a D.S.S. (Department of Social Services) case.

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. You should contact the Office of the Public Defender, or let the Juvenile Court know you need to have a lawyer appointed for you.

Even if you do not have the right to have the court appoint a lawyer for you or to be represented through the Office of the Public Defender, 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. The court may require D.S.S. or the adoptive parents to pay for the adoption counseling and guidance but does not have to do so. 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 have made a written agreement with the adoptive parents for future contact (known as a post-adoption agreement), a copy of that agreement must be attached to the signed consent form. If you have a post-adoption agreement, and, after the adoption, the adoptive parents do not do what they agreed to do, it will not affect the adoption or your consent to the adoption. However, if that happens, you have the right to ask a judge to make them do what they agreed to do. The judge can order you and the adoptive parents to go to mediation, order the adoptive parents to do what they agreed to do, or change the agreement if the judge decides that it is in the child's best interest.

IF YOU SIGN THE CONSENT FORM, AND ADOPTION IS GRANTED, YOU WILL BE GIVING UP ALL RIGHTS AND RESPONSIBILITIES RELATING TO THE CHILD. If you have a post-adoption agreement, you will keep only the rights the agreement gives you. Violation of the agreement will not affect your consent or the adoption.

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. If the adoption case is already filed in court, you must revoke your consent within 30 days after the date that you sign the consent form. If the adoption case has not been filed in court, you must revoke your consent within 30 days after the adoption petition is filed. 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:

Juvenile Clerk, Circuit Court for __________ at __________ (Address).

The revocation must be sent to the court, not to your social worker, lawyer, 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 Juvenile Clerk's office within the later of 30 days after the date you sign the consent form or 30 days after the date the adoption petition is filed, it will be too late, and you will not be able to withdraw the consent or stop the adoption from being granted.

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 Juvenile 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 that reasonable and customary charges or fees for adoption counseling, hospital, legal, or medical services may be paid.

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 Resources 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.

You may be asked to sign a separate form (authorization) to allow the adoptive parents to get your child's medical and mental health records or your medical and mental health records. If you agree to allow access to this information, the records given to the adoptive parents will not include identifying information about you unless identifying information was previously exchanged by agreement.

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.

1. Language.

2. Name.

3. Age.

4. Child.

The child who is the subject of this consent was born on __________(date) at __________(name of hospital or address of birthplace), in __________(city, state, and county of birth).

5. Status as Parent. Check all that apply.

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:

Check one of the following:

Check one of the following:

I have read carefully and understand the instructions in 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.