Instructions for Form CD-49 "Specific Consent to Termination of Parental Rights and Consent to Adoption Form" - Missouri

This document contains official instructions for Form CD-49, Specific Consent to Termination of Parental Rights and Consent to Adoption Form - a form released and collected by the Missouri Department of Social Services.

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CD-49
(08/11)
SPECIFIC CONSENT TO TERMINATION OF PARENTAL RIGHTS AND CONSENT TO
ADOPTION FORM
PURPOSE:
This form should not be used by Children’s Division. The purpose of this form is to provide
written consent when a parent is considering consent to termination of parental rights and
allowing the child to be placed for adoption and a specific adoptive family has been indicated.
The form is to be completed by the parent with the assistance of a social worker, attorney or
intermediary. The form should be signed by all appropriate parties.
NUMBER OF COPIES AND DISTRIBUTION:
The completed, signed and notarized original consent should be provided to the court to become
part of the judicial record. Provide a copy to the parent. Copies may be made for the
attorney/intermediary, guardian ad litem and juvenile officer.
NOTE: Parents should never be required to sign an undated, unspecified or incomplete consent
form.
INSTRUCTIONS FOR COMPLETION:
Those sections of the form which do not ask for written information should be read by the parent
and questions should be asked of the parent to insure their understanding.
The social worker, attorney or intermediary assisting the parent should document in their case
file that the information was read by or read to the parent and inquiry made of the birth parent
regarding their understanding of the information provided to them.
Complete the indicated city/county information and Child’s name as well as the name, DOB,
age, sex and address of the parent executing the consent.
Complete Number 1 (A) or (B) by indicating mother or possible father and entering the child’s
birth date and place of birth and have client initial the appropriate box.
Complete Number 2 by filling in the blank and reviewing the information with the client,
insuring they understand all that has been read and have the client initial.
Read and review the box below number 2 with the client, insuring that they understand all that
has been read and have the client initial.
Review Number 3 completely insuring the client understands and have the client initial.
1
CD-49
(08/11)
SPECIFIC CONSENT TO TERMINATION OF PARENTAL RIGHTS AND CONSENT TO
ADOPTION FORM
PURPOSE:
This form should not be used by Children’s Division. The purpose of this form is to provide
written consent when a parent is considering consent to termination of parental rights and
allowing the child to be placed for adoption and a specific adoptive family has been indicated.
The form is to be completed by the parent with the assistance of a social worker, attorney or
intermediary. The form should be signed by all appropriate parties.
NUMBER OF COPIES AND DISTRIBUTION:
The completed, signed and notarized original consent should be provided to the court to become
part of the judicial record. Provide a copy to the parent. Copies may be made for the
attorney/intermediary, guardian ad litem and juvenile officer.
NOTE: Parents should never be required to sign an undated, unspecified or incomplete consent
form.
INSTRUCTIONS FOR COMPLETION:
Those sections of the form which do not ask for written information should be read by the parent
and questions should be asked of the parent to insure their understanding.
The social worker, attorney or intermediary assisting the parent should document in their case
file that the information was read by or read to the parent and inquiry made of the birth parent
regarding their understanding of the information provided to them.
Complete the indicated city/county information and Child’s name as well as the name, DOB,
age, sex and address of the parent executing the consent.
Complete Number 1 (A) or (B) by indicating mother or possible father and entering the child’s
birth date and place of birth and have client initial the appropriate box.
Complete Number 2 by filling in the blank and reviewing the information with the client,
insuring they understand all that has been read and have the client initial.
Read and review the box below number 2 with the client, insuring that they understand all that
has been read and have the client initial.
Review Number 3 completely insuring the client understands and have the client initial.
1
Complete Number 4 with the client by obtaining their number of educational years.
Complete Number 5 by choosing one or more of the listed option and have the client initial. If
choosing the last option, fill in the native language and name of interpreter.
Complete Number 6 by choosing one of the five options. Fill in the blanks and have the client
initial the appropriate box.
Complete Number 7 by having the client choose one of the two options pertaining to the Indian
Child Welfare Act and have the client initial the appropriate box.
Complete Number 8 by reviewing the information with the client and insuring they understand
all that has been read and have the client initial.
Complete Number 9 reading and reviewing the two options; that the client has legal
representation OR has waived that right to an attorney then have the client initial the appropriate
box. Write in the name of the attorney, if the client is represented.
Complete Number 10 by reading and filling in the name of the County, State and case number.
Review and have the client initial it.
Review Number 11, fill in the County name, completely insuring the client understands all seven
statements and have the client initial the box.
Read and review Number 12, allowing the client to choose from one of the two options.
Read and review Number 13, adding names to any possible fathers of the Child if applicable and
have the client initial.
Review Number 14 completely insuring the client understands all four statements and have the
client initial the box.
Fill in the parent’s full legal name. Obtain the parent’s signature, certifying that they have read,
considered and understood all the above statements.
Have the notary complete the Acknowledgement section and certification.
OR
When a notary is not available and the court directs that the consents be obtained, complete the
witness section with two witness signatures.
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RETENTION AND DISTRIBUTION:
Provide the original consent to the court.
Provide a copy of the consent to the parent
Retain a copy in the client record as long as the record is retained.
MEMORANDUM HISTORY: CD11-64
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