Form CFS403 "Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Dcfs Case" - Illinois

What Is Form CFS403?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFS403 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS403 "Final and Irrevocable Consent to Adoption by a Specified Person or Persons: Dcfs Case" - Illinois

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CFS 403
Rev 3/2019
State of Illinois
Department of Children and Family Services
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A
SPECIFIED PERSON OR PERSONS: DCFS CASE
I,
, the mother/father of
(circle one)
a male/female child, state that:
(circle one)
1)
My child,
was born on
at
Hospital in the City/Town of
in
County, State of
.
2)
I reside at
, County of
, State of
Zip Code
.
Mail may also be sent to me at this address:
,
in care of
.
My home telephone number is
.
My cell telephone number is
.
My e-mail address is
.
3)
I,
, am
years of age.
4)
I enter my appearance in this action for my child to be adopted by the person or persons specified herein by me and
waive service of summons on me in this action only.
5)
I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and Responsibilities in Illinois for
Final and Irrevocable Consents to Adoption by a Specified Person or Persons for DCFS Cases before signing this
Consent and that I have had time to read this form or have it read to me and that I understand the rights and
responsibilities described in this form. I understand that if I do not receive any of my rights as described in this form, it
shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person or Persons.
6)
I do hereby consent and agree to the adoption of such child by
(names of current foster parent(s) or caregiver(s), hereinafter referred to as the "specified person or persons") only.
7)
I wish to sign this consent and I understand that by signing this consent I irrevocably and permanently give up all my
parental rights I have to my child.
8)
I understand that this consent allows my child to be adopted by the specified person or persons only and that I
cannot under any circumstances after signing this document change my mind and revoke or cancel this consent.
If the parent consents to an adoption by two specified persons, complete the following:
8a.
I understand that I cannot change my mind or revoke this consent or recover custody of my child on the
basis that the specified persons divorce or are granted a dissolution of a civil union or that one of the
specified persons has died.
8b.
I understand that if the specified persons get a divorce or are granted a dissolution of a civil union before the
petition to adopt my child is granted, this consent remains valid only for __________________________
(name only one specified person) to adopt my child.
8c.
I understand that if either of the specified persons dies before the petition to adopt my child is granted, this
consent remains valid for the surviving person to adopt my child.
Page 1 of 3
CFS 403
Rev 3/2019
State of Illinois
Department of Children and Family Services
FINAL AND IRREVOCABLE CONSENT TO ADOPTION BY A
SPECIFIED PERSON OR PERSONS: DCFS CASE
I,
, the mother/father of
(circle one)
a male/female child, state that:
(circle one)
1)
My child,
was born on
at
Hospital in the City/Town of
in
County, State of
.
2)
I reside at
, County of
, State of
Zip Code
.
Mail may also be sent to me at this address:
,
in care of
.
My home telephone number is
.
My cell telephone number is
.
My e-mail address is
.
3)
I,
, am
years of age.
4)
I enter my appearance in this action for my child to be adopted by the person or persons specified herein by me and
waive service of summons on me in this action only.
5)
I hereby acknowledge that I have been provided a copy of the Birth Parent Rights and Responsibilities in Illinois for
Final and Irrevocable Consents to Adoption by a Specified Person or Persons for DCFS Cases before signing this
Consent and that I have had time to read this form or have it read to me and that I understand the rights and
responsibilities described in this form. I understand that if I do not receive any of my rights as described in this form, it
shall not constitute a basis to revoke this Final and Irrevocable Consent to Adoption by a Specified Person or Persons.
6)
I do hereby consent and agree to the adoption of such child by
(names of current foster parent(s) or caregiver(s), hereinafter referred to as the "specified person or persons") only.
7)
I wish to sign this consent and I understand that by signing this consent I irrevocably and permanently give up all my
parental rights I have to my child.
8)
I understand that this consent allows my child to be adopted by the specified person or persons only and that I
cannot under any circumstances after signing this document change my mind and revoke or cancel this consent.
If the parent consents to an adoption by two specified persons, complete the following:
8a.
I understand that I cannot change my mind or revoke this consent or recover custody of my child on the
basis that the specified persons divorce or are granted a dissolution of a civil union or that one of the
specified persons has died.
8b.
I understand that if the specified persons get a divorce or are granted a dissolution of a civil union before the
petition to adopt my child is granted, this consent remains valid only for __________________________
(name only one specified person) to adopt my child.
8c.
I understand that if either of the specified persons dies before the petition to adopt my child is granted, this
consent remains valid for the surviving person to adopt my child.
Page 1 of 3
9)
I understand that this consent will be void if:
(a) the Department places my child with someone other than the specified person or persons; or
(b) a court denies the adoption petition for the specified person or persons to adopt my child; or
(c) the DCFS Guardianship Administrator refuses to consent to my child’s adoption by the specified
person or persons on the basis that the adoption is not in my child’s best interest.
I understand that if this consent is void, I have parental rights to my child, subject to any applicable court orders
including those entered under Article II or the Juvenile Court Act of 1987, unless and until I sign a new consent or
surrender or my parental rights are involuntarily terminated. I understand that if this consent is void, my child may be
adopted by someone other than the specified person or persons only if I sign a new consent or surrender, or my parental
rights are involuntarily terminated. I understand that if this consent is void, the Department will notify me within 30
days using the addresses and telephone numbers I provided in paragraph 2 of this form. I understand that if I receive
such notice, it is very important that I contact the Department immediately and preferably within 30 days, to have input
into the plan for my child’s future.
10)
I understand that if a petition for adoption of my child is filed by someone other than the specified person or persons,
the Department will notify me within 14 days after the Department becomes aware of the petition. The fact that
someone other than the specified person or persons files a petition to adopt my child does not make this consent void.
11)
If a person(s) other than the specified person or persons files a petition to adopt my child or if the consent is void under
paragraph 9, the Department will send written notice to me using the mailing address and email address provided by me
in paragraph 2 of this form. The Department will also contact me using the telephone numbers I provided in paragraph
2 of this form. It is very important that I let the Department know if any of my contact information changes. If I do not
let the Department know if any of my contact information changes, I understand that I may not receive notification from
the Department if this consent is void or if someone other than the specified person or persons files a petition to adopt
my child. If any of my contact information changes, I should immediately notify:
Caseworker’s name and telephone number:
Agency name, address, zip code, and telephone number:
Supervisor’s name and telephone number:
DCFS Advocacy Office for Children and Families: 1-800-232-3798.
12)
I expressly acknowledge that paragraph 9 (and paragraphs 8a and 8b, if applicable) do not impair the validity and
finality of this consent under any circumstances.
13)
I have read and understand the above and I am signing it as my free and voluntary act.
Dated this
day of
, 20
Signature of Parent
Page 2 of 3
CERTIFICATE OF ACKNOWLEDGMENT OF CONSENT
I,
(name of Judge or other person),
(official title and address), certify that
, personally known to me to be the same person
whose name is subscribed to the foregoing Final and Irrevocable Consent to Adoption by a Specified Person or Persons: DCFS
Case, appeared before me this day in person and acknowledged that (she)(he) signed and delivered such consent as a free and
voluntary act for the specified purpose.
I have fully explained that by signing this consent this parent is irrevocably and permanently relinquishing all
parental rights to the child so that the child may be adopted by a specified person or persons, and this parent has stated that
such is (her)(his) intention and desire. I have fully explained that this consent is void only if:
(a)
the placement is disrupted and the child is moved to a different placement; or
(b)
a court denies the petition for adoption; or
(c)
the Department of Children and Family Services Guardianship Administrator refuses to consent to
the child’s adoption by a specified person or persons on the basis that the adoption is not in the
child’s best interests.
Dated this
day of
, 20
(Signature)
ACKNOWLEDGMENT OF SIGNATURE
State of Illinois
)
) SS.
County of
)
I,
, Notary Public, in and for said County and State, do hereby
certify that
, personally known to me to be the same person whose name
is subscribed in the foregoing Certificate of Acknowledgment, appeared before me in person this date and acknowledged that
she signed such as his/her free and voluntary act and that the statements made in said certificate are true.
Given under my hand a notarial seal this
day of
, 20
Notary Public
(Seal)
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