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

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

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I solemnly affirm under the penalties of perjury that the<br />

contents of the foregoing Consent Form are true to the best of my<br />

knowledge, information, and belief.<br />

_______________________ _____________________________________<br />

(Date) (Signature)<br />

(d) Form of Consent of Person to be Adopted<br />

_____________________________________<br />

(Address)<br />

_____________________________________<br />

(Telephone Number)<br />

The consent of a person to be adopted shall be in<br />

substantially the following form.<br />

1. Name.<br />

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

OR<br />

REQUEST FOR ATTORNEY<br />

My name is _________________________________________________ .<br />

2. Age and Place of Birth.<br />

(a) I am at least 10 years old. My date of birth is _______<br />

_____________________.<br />

(b) I was born at ___________________________________________<br />

_______________________________________________________________ ,<br />

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

in ____________________________________________________________.<br />

-84-

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