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r1r STANDING COMMITTEE ON RULES OF PRACTICE - Maryland ...

r1r STANDING COMMITTEE ON RULES OF PRACTICE - Maryland ...

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C<strong>ON</strong>SENT TO INDEPENDENT ADOPTI<strong>ON</strong> <strong>OF</strong><br />

____________________________________________<br />

WITH TERMINATI<strong>ON</strong> <strong>OF</strong> PARENTAL RIGHTS<br />

Use a pen to fill out this form. You must complete each section.<br />

A. Identifying Information<br />

1. Language.<br />

I understand English, or this consent form has been<br />

translated into ______________________________________________, a<br />

language that I understand.<br />

2. Name.<br />

3. Age.<br />

My name is ____________________________________________.<br />

My date of birth is ___________________________________.<br />

4. Child.<br />

The child who is the subject of this consent was born on<br />

__________________ at __________________________________________,<br />

(date) (name of hospital or address of birthplace)<br />

in ____________________________________________________________ .<br />

(city, state, and county of birth)<br />

5. Status as Parent. Check all that apply.<br />

(a) I am<br />

[ ] the mother of the child<br />

[ ] the father of the child<br />

[ ] alleged to be the father of the child<br />

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