MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION GENERAL CONSENT TO TERMINATION OF PARENTAL RIGHTS AND ADOPTION
IN THE	DIVISION
OF THE CIRCUIT COURT OF THE CITY/COUNTY OF
STATE OF MISSOURI
In re the Matter of	)
)	Case No
(“Child”)
CONSENT TO TERMINATION OF PARENTAL RIGHTS AND ADOPTION
My name is	. I reside at	.
(full legal name)	(address)
I am a	( male female) person and my date of birth is	. I acknowledge that the following
statements are completed by me and each statement is true, complete, and correct to the best of my knowledge:
The Child,	was born on
(full legal name)
in	.
(city/county/state)
My relationship to the Child is:
(A) I am the ( mother father) of the Child.
OR
(B) I have been named as a possible birth father for the Child. I deny that I am the birth father of the Child;
however, in order to facilitate the location of a stable and secure home for the Child, I am willing to execute this Consent and do so with the full understanding that its terms will apply to me if it turns out that I am in fact the birth father of the Child. I understand that if I deny paternity, but consent to adoption, I waive any future interest in the child.
Because I believe it is in the best interest of the Child and his or her future welfare, I voluntarily and of my own
free will forever consent to the termination of parental rights and obligations and consent to the lawful adoption of the Child.
I understand and intend that this consent to TERMINATION OF MY PARENTAL RIGHTS AND CONSENT TO adoption is final once it is accepted and approved by a court of competent jurisdiction.
I understand that as the parent of the Child, I may have the primary right to custody of the Child if I so
choose, even if I am a minor, and that by signing this Consent I am giving up any such right along with all my other parental rights and obligations.
I have completed	years of education.
I read and understand the English language; or
I understand English and this Consent form was read to me; or
this Consent form was read to me in my native language of
by	.
(name of interpreter)

Check and complete all that apply:
At the time of the Child’s birth, I was married to	.
(full legal name)
I was married to	within the last 300 days prior to the child’s birth.
(full legal name)
I am not married.
My marriage to	was legally dissolved on	.
(full legal name)	(date)
Indian Child Welfare Act:
As far as I know, neither I, nor any member of my family, which includes the Child, is a member of, or
eligible for membership in a federally recognized American Indian Tribe or Alaskan Native Village.
OR
I, or a member of my family, which includes the Child, is a member of, or is eligible for membership in a
federally recognized American Indian Tribe or Alaskan Native Village. Please see the relevant section
at the end of this document.
I have been informed of my right to be represented by my own attorney. I have also been informed that an
attorney can be appointed to me if I cannot afford to hire an attorney. I also understand that I may review this
document and seek advice of an attorney before signing this Consent.
I have talked to and am represented by	regarding this Consent.
(name of attorney)
OR
I HEREBY WAIVE MY RIGHT TO AN ATTORNEY.
The Child is currently under the jurisdiction of the juvenile court/family court in	County,
, in case number	.
(State)
By completing and signing this Consent I certify to the Court that I:
Hereby submit to the jurisdiction of the Court of the State of Missouri.
Understand that this Consent will be filed with the juvenile court/family court in
County, Missouri and any other court in which proceedings
concerning the Child may be pending.
Have had enough time to carefully consider whether or not consent to termination of parental rights and adoption is in my own best interest and the best interest of the Child.
Have given careful thought to my decision to proceed with this Consent.
Am not under the influence of any drug, medication, or other substance which might affect my reasoning or judgment.
Have signed this Consent to termination of parental rights and adoption of my own free will and without any duress or undue influence from anyone.
Have not been given any money or gifts, and no one has promised to provide me any money or gifts in exchange for my consent other than payment of expenses allowed by law.

I choose to:
waive service of summons and a copy of any petition seeking the termination of my parental rights and adoption as may hereafter be filed in any court of competent jurisdiction. I hereby waive my right to
appear in any such proceedings and consent to a hearing thereof, at any time, without further notice to me;
OR
reserve the right to receive service of summons and a copy of any petition seeking the termination of my parental rights and adoption as may hereafter be filed in any court of competent jurisdiction regarding the child.
I understand the importance of identifying all possible fathers of the Child and may provide the names of all
such persons:	.
I am the birth mother, and I have not misrepresented to any man who could be the father of this child that:
I was not pregnant; that the pregnancy was terminated; that the child has died; or that the child is not his.
I CERTIFY BY MY SIGNATURE BELOW THAT I HAVE READ, CONSIDERED, AND UNDERSTAND ALL THE ABOVE STATEMENTS.
I,	, hereby acknowledge that the statements provided above
(full legal name)
are true, complete and correct.
Signature of Parent	Date	Time
Signature of Parent’s Attorney	Date	Time
Signature of Parent’s Guardian ad Litem (if required by §453.030.12 RSMo or other applicable law)	Date	Time
ACKNOWLEDGEMENT OR WITNESSES TO PARENT’S CONSENT
STATE OF MISSOURI	)
)
COUNTY OF	)
On this	day of	, in the year	, before me personally
(month)
appeared	known to me to be the person who executed this
(full legal name of parent)
Consent to Termination of Parental Rights and Adoption and acknowledged to me that she/he executed the same for the purposes herein stated.
Notary Public
My Commission Expires:

The undersigned witnesses certify by their signatures that
(full legal name of parent)
signed the Consent and that the Consent was knowingly and freely given. We further
certify that we are not the prospective adoptive parents of the above named child.
Printed Name of Witness	Date	Time
Signature of Witness	Full Address of Witness
Printed Name of Witness	Date	Time
Signature of Witness	Full Address of Witness
INDIAN CHILD WELFARE ACT:
Pursuant to the Indian Child Welfare Act (25 U.S.C. §1913(a)), “Any parent or Indian custodian voluntarily consents…to termination of parental rights, such consent shall not be valid unless executed in writing and recorded before a judge of a court of competent jurisdiction and accompanied by the presiding judge's certificate that the terms and consequences of the consent were fully explained in detail and were fully understood by the parent or Indian custodian. The court shall also certify that either the parent or Indian custodian fully understood the explanation in English or that it was interpreted into a language that the parent or Indian custodian understood. Any consent given prior to, or within ten days after, birth of the Indian child shall not be valid.” If the Indian Child Welfare Act is applicable then pursuant to 25 U.S.C. §1913(c), a “Parent may withdraw consent in voluntary TPR or adoptive placement for any reason at any time before the entry of a final decree of termination or adoption.”
The foregoing CONSENT TO TERMINATION OF PARENTAL RIGHTS AND ADOPTION executed by
In re the Matter of
(Parent’s Name)	(Child)
has been reviewed, accepted and approved.
By:	Date:
Family Court Commissioner Division
By:	Date:
Judge Division