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

1. Name.
My name is _________________________________________________.
2. Age and Competence.
My date of birth is _____________________ and I am capable of
understanding what this consent means.
3. Status as Parent. Check all that apply.
(a) I am [ ] the mother [ ] the father (or) [ ] alleged to
be the father of _____________________________________ , born on
________________________________________, _______________________
at ____________________________________________________________ ,
(name of hospital or address of birthplace)
in _____________________________________________________________.
(city, state, and county of birth)
(b) I was married to the mother of the child [ ] at the time
of conception [ ] at the time the child was born.
4. RIGHT TO ATTORNEY.
I understand that:
(a) The court will appoint an attorney for me if I am under
18 years of age or if, because of a disability, I am incapable of
consenting to the adoption/guardianship or of effectively
participating in the adoption/guardianship proceeding.
(b) Even if I am not entitled to a court-appointed attorney, I
am entitled to consult an attorney chosen by me. If this is a
consent to an adoption, the adoptive parents may agree to pay all
or part of the attorney's fees on my behalf and, if this is an
independent adoption (that is, where an agency is not involved),
the court may order the adoptive parents to do so.
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