Attorney Name
Address
Phone Number
MONTANA [DISTRICT NUMBER] JUDICIAL DISTRICT COURT,
[COUNTY NAME] COUNTY
)
IN THE MATTER OF THE ADOPTION ) Cause No.
OF [NAME OF MINOR CHILD], )
)
A minor child, ) AFFIDAVIT OF WAIVER
) OF ALL PARENTAL RIGHTS,
by ) RELINQUISHMENT OF CHILD,
) AND CONSENT TO ADOPTION
[NAME OF PETITIONER], )
)
Petitioner. )
STATE OF ________________ )
: ss
County of _________________ )
1. I, [NAME OF RELINQUISHING PARENT], first being duly sworn, state the
following:
2. I am the [natural father]/ [natural mother] of the minor child, [NAME OF MINOR
CHILD], who was born on [DATE OF BIRTH OF MINOR CHILD] in [PLACE OF BIRTH OF
MINOR CHILD]. (§ 42-2-412(1)(c), MCA) I am over 18 years of age. I was born on
_________ ____, 19__. My current mailing address is [ADDRESS, CITY, STATE, ZIP OF
RELINQUISHING PARENT]. (§ 42-2-412(1)(b), MCA)
Affidavit of Waiver of All Parental Rights, Relinquishment of Child, and Consent to Adoption
3. After carefully considering the best interests of my minor child, I hereby relinquish
care, custody, and control of the minor child to her MOTHER/FATHER, [NAME OF
STEPPARENT'S SPOUSE], [ADDRESS, CITY, STATE OF RESIDENCE OF STEPPARENT'S
SPOUSE] and to [NAME OF STEPPARENT], (§ 42-2-412(1)(d), MCA), who resides at
[ADDRESS, CITY, STATE OF RESIDENCE OF STEPPARENT] (§ 42-2-412(1)(d), MCA)
4. By signing this document, I understand that I am relinquishing all of my parental
rights to the minor child, [NAME OF MINOR CHILD]. My relinquishment is voluntary,
irrevocable, and is given freely with a clear mind. I have not been unduly influenced by anyone
in making this relinquishment.
5. I knowingly, unequivocally, and voluntarily transfer permanent legal and physical
custody to the child’s mother, [NAME OF STEPPARENT'S SPOUSE], and [NAME OF
STEPPARENT]. (§ 42-2-412(2)(b), MCA)
6. I knowingly, unequivocally, and voluntarily give my consent to have any court of
competent jurisdiction terminate my parental rights and award permanent legal custody with the
right to consent to adoption to the child’s mother. (§ 42-2-412(2)(b), MCA)
7. I knowingly, unequivocally, and voluntarily give my consent to have [NAME OF
STEPPARENT] adopt the minor child, [NAME OF MINOR CHILD], (§ 42-4-301(1); 42-2-
402(1)(b)), who resides at [ADDRESS, CITY, STATE OF RESIDENCE OF STEPPARENT] (§
42-2-412(1)(d), MCA)
8. I understand that upon my signature of this document, it is final and may not be
revoked or set aside for any reason, including failure of an adoptive parent to permit me to visit
or communicate with the child, except as provided for in Section 42-2-411, MCA. (§ 42-2-
412(3)(a), MCA)
Affidavit of Waiver of All Parental Rights, Relinquishment of Child, and Consent to Adoption
9. I understand that, upon the adoption of this minor child, all of my parental rights and
obligations with respect to the minor child, [NAME OF MINOR CHILD], will be extinguished,
except for arrearages for child support unless waived. (§ 42-2-412(3)(b), MCA)
10. I understand that this relinquishment will remain valid whether or not any agreement
for visitation or communication with the child is later performed. (§ 42-2-412(3)(b), MCA)
11. I have not been offered any money or anything of value for execution of this
document. (§ 42-2-412(3)(e)(ii), MCA)
12. I expressly waive my rights to notice of proceedings regarding this child, including
any hearing terminating my parental rights and awarding permanent legal custody to the child’s
mother and [NAME OF STEPPARENT]. (§ 42-2-412(4), MCA)
13. I further waive my right to notice of any adoption proceeding and expressly consent
that any adoption proceeding may be heard at any time without notice to me. (§ 42-2-412(4),
MCA)
14. I acknowledge that I have received a copy of this document. (§ 42-2-412(3)(c)(i),
MCA)
DATED this _______ day of ________________ , 20 _______.
Executed at ___________________________________ at _______ o’clock _____. m.
(location)
(§ 42-2-412(1)(a), MCA)
___________________________________
[NAME OF RELINQUISHING PARENT]
Relinquishing Parent
SUBSCRIBED AND SWORN TO before me this __ day of ___________ , 20__ by [NAME OF
RELINQUISHING PARENT].
__________________________________________
Notary's Signature
Notary Public for the State of _________________
Affidavit of Waiver of All Parental Rights, Relinquishment of Child, and Consent to Adoption
Printed name of notary _______________________
Title or rank: ______________________________
Residing at _______________________________
My Commission Expires: ____________________
(Seal)
Affidavit of Waiver of All Parental Rights, Relinquishment of Child, and Consent to Adoption
