Type on the first line, "I (your full legal name), born on (your birthday), am the (mother or father) of the child, (child's full legal name) who was born on (child's birthday and city where the child was born as stated on the birth certificate)."
Show the judge or family court representative that you fully understand what is at stake by typing, "I fully comprehend my legal rights as a parent and am of sound mind. I am aware that I do not have to agree to the adoption of my child. I understand that by signing this statement, I am bound to voluntarily and permanently relinquish my full rights as a parent."
Demonstrate that this statement was not coerced by typing on the third line, "On my own volition, I fully and permanently surrender legal and physical custody of my child and consent to the adoption of my child by the petitioners. I am neither being compensated or forced to submit this statement under duress."
Sign and date the statement and include your permanent home address. Without a signature, the document will be deemed incomplete by the individual presiding over the adoption.