Section 26-10A-12

Persons who may take consent or relinquishments; forms.

(a) A consent of the natural mother taken prior to the birth of a child shall be signed or confirmed before a judge of probate. At the time of taking the consent the judge shall explain to the consenting parent the legal effect of signing the document and the time limits and procedures for withdrawal of the consent and shall provide the parent with a form for withdrawing the consent in accordance with the requirements of Sections 26-10A-13 and 26-10A-14.

(b) All other pre-birth or post-birth consents or relinquishments shall be signed or confirmed before:

(1) A judge or clerk of any court which has jurisdiction over adoption proceedings, or a public officer appointed by such judge for the purpose of taking consents; or

(2) A person appointed to take consents who is appointed by any agency which is authorized to conduct investigations or home studies provided by Section 26-10A-19, or, if the consent is taken out of state, by a person appointed to take consents by any agency which is authorized by that state's law to conduct investigations and home studies for adoptions; or

(3) A notary public.

(c) Except as otherwise provided in subsection (d), the form for the consent or relinquishment or the withdrawal of the consent or relinquishment shall state in substantially the same form as follows:



______________COUNTY )


1. I, ________________________________________
(name of person consenting or relinquishing)
the _______________________________________ of
(parents, legal guardian, agency)
(a) a minor ___________________________________
(state any names by which the minor has been known)
born ____________, __.
(b) an unborn child whose expected date of birth is
______________, do hereby:
(a) consent to the adoption of the said minor by
(name of petitioners, unless identity waived)
(b) relinquish the said minor for the purpose of adoption to
(name and address of agency)

in order that said minor may have all the privileges which may be accorded to (him) (her) by the laws of Alabama upon (his) (her) legal adoption;

2. I am executing this document voluntarily and unequivocally thereby [consenting to the adoption of] [relinquishing] said minor;

3. I understand that by signing this document and the subsequent court order to ratify the consent, I will forfeit all rights and obligations and that I understand the [consent to the adoption] [relinquishment] and execute it freely and voluntarily;

4. I understand that the [consent to the adoption] [relinquishment] may be irrevocable, and I should not execute it if I need or desire psychological or legal advice, guidance or counseling;

5. I have received or been offered a copy of this document;

6. I waive the right to know the identity of each petitioner who petitions to adopt the said minor child;

7. [I waive further notice of the adoption proceedings by the execution of this relinquishment to the named agency];


[I waive further notice of the adoption proceedings by the execution of this consent, unless there is a contest or appeal of the adoption proceedings];

8. I understand that notice of withdrawal of [consent] [relinquishment] must be mailed to

(county where consent or petition is filed if known)
Probate Court at the following address ______________]
or [________________________________________
(name and address of agency with whom document is filed or the
petitioners or their attorney if county where petition is filed is unknown)
and that such withdrawal must be mailed within five days after the birth of said minor or the execution of this document whichever comes last;

9. I do hereby request that the judge of probate make all such orders and decrees as may be necessary or proper to legally effectuate said adoption.

Given under my hand at ____o'clock, ______ day of ____________, __, at ___________________

(address of filing)

___________(SEAL) Affiant's Signature

"I _______________, sign my name to this instrument this _____ day of__________, __, and being first duly sworn, do hereby declare to the undersigned authority that I execute it as my free and voluntary act for the purposes therein expressed, and that I am _____ years of age or older, of sound mind, and under no constraint or undue influence."

Affiant's Signature
COUNTY OF _______)

Subscribed, sworn to and acknowledged before me by ________________, this_______________day of _______, __.

SEAL(Signed) __________
(Official Capacity of Officer)
I acknowledge receipt of two copies of this document.

I _______, on this _______ day of ____________, __, at


_____________ a.m./p.m. in the presence of the two witnesses whose

(time of day)

signatures and addresses are subscribed below, hereby withdraw the adoption [consent] [relinquishment] previously signed by me.

WitnessAffiant's Signature

(d) The form for the consent or relinquishment or the withdrawal of consent or relinquishment for an adult, adopted or sought to be adopted, shall be developed by the Administrative Office of Courts.

(Acts 1990, No. 90-554, p. 912, §12; Act 98-101, p. 118, §1.)