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STATUTORY INSTRUMENTS. S.I. No. 519 of 2010 ———————— ADOPTION ACT 2010 (CONSENT TO ADOPTION ORDER) (FORMS) REGULATIONS 2010 (Prn. A10/1611)

STATUTORY INSTRUMENTS. - Adoption Authority of … · [519] 3 SCHEDULE forms of consent to adoption Form 1 The Adoption Authority of Ireland AFFIDAVIT OF CONSENT TO ADOPTION (For

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STATUTORY INSTRUMENTS.

S.I. No. 519 of 2010

————————

ADOPTION ACT 2010 (CONSENT TO ADOPTION ORDER) (FORMS)REGULATIONS 2010

(Prn. A10/1611)

2 [519]

S.I. No. 519 of 2010

ADOPTION ACT 2010 (CONSENT TO ADOPTION ORDER) (FORMS)REGULATIONS 2010

I, BARRY ANDREWS, Minister of State at the Department of Health andChildren, in exercise of the powers conferred on me by section 150 of the Adop-tion Act 2010 (No. 21 of 2010) and the Health and Children (Delegation ofMinisterial Functions) Order 2010 (S.I. No. 508 of 2010), hereby make the fol-lowing regulations:

1. These regulations may be cited as the Adoption Act 2010 (Consent toAdoption Order) (Forms) Regulations 2010.

2. These regulations come into operation on 2 November 2010.

3. Each of the forms set out in the Schedule shall be used in the case andmanner indicated in the form.

Notice of the making of this Statutory Instrument was published in“Iris Oifigiúil” of 5th November, 2010.

[519] 3

SCHEDULE

forms of consent to adoption

Form 1

The Adoption Authority of Ireland

AFFIDAVIT OF CONSENT TO ADOPTION

(For use by a mother where the identity of the applicant(s) is known to her)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

spinster/married/divorced/widow (*a), aged eighteen years and upwards (or, ifunder eighteen, aged ................. years), make oath and say as follows:

1. I am aware that an application is about to be made or has been made by

........................................................................................................................(names(s))

of .................................................................................................................... (address)

for an adoption order in respect of the said child.

2. I am the mother of the said child.

3. I did / I did not marry the father of the said child. (*b)

4. I am / I am not the sole guardian of the said child. (*c)

5. The father has/has not been appointed a guardian of the said child pursuantto a court order or otherwise. (*d)

6. To the best of my knowledge and belief the father has / has not institutedproceedings in relation to access to, or guardianship or custody of, the said child.(*e)

7. The said child is not less than six weeks old, having been born on the............ day of ......... 20....

8. I know that the religion of the male applicant is .............................................and that the religion of the female applicant is ........................................................

4 [519]

9. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

10. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

11. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

12. I have been informed and I understand that this consent may be with-drawn, at any time before the making of the adoption order, by my so informingthe Adoption Authority of Ireland, Shelbourne House, Shelbourne Road,Dublin 4, and that on the making of the adoption order my consent becomesirrevocable.

13. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

14. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

15. I say that my wishes in respect of the matters referred to in paragraph 13above are as follows:

(i) I do/I do not wish to be heard on the application for the adoptionorder; (*f)

(ii) I do/I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*g)

16. I understand that this affidavit may be used as evidence that I consent tothe adoption order being made.

Signature .......................................................................

Sworn at........................................................................ in the county of

....................................................................................................................... on this

................ day of ......................... 20....... .

before me and I know the deponent (or I know ......................................................,

who certifies to me that (s)he knows the deponent).

[519] 5

Signature .......................................................................

Description (*h) .............................................................................................................

(*a), (*b), (*c), (*d), (*e), (*f) and (*g): Delete words which do not apply. Alldeletions must be initialled by the deponent and by the person before whomthe affidavit is sworn.

(*h) If the affidavit is being sworn in the State, it should be sworn before aCommissioner for Oaths; if it is being sworn elsewhere, it should be swornbefore a Notary Public or other person duly authorised to administer oaths.

6 [519]

Form 2

The Adoption Authority of Ireland

AFFIDAVIT OF CONSENT TO ADOPTION

(For use by a person other than the mother where the identity of the applicant(s)is known to the consenting party)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

bachelor/spinster/married/divorced/widow/widower (*a), aged eighteen yearsand upwards (or, if under eighteen, aged................. years), make oath and sayas follows:

1. I am aware that an application is about to be made or has been made by

........................................................................................................................(names(s))

of .................................................................................................................... (address)

for an adoption order in respect of the said child.

2. I am the father of the said child / a guardian of the said child / a personhaving charge of or control over the said child. (*b)

3. I am the father of the said child and I married the mother of the said child.(*c)

4. The said child is not less than six weeks old, having been born on the...................... day of .............., 20 .........

5. I know that the religion of the male applicant is ..............................................and that the religion of the female applicant is ........................................................

6. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

7. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

[519] 7

8. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

9. I have been informed and I understand that this consent may be withdrawn,at any time before the making of the adoption order, by my so informing theAdoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4,and that on the making of the adoption order my consent becomes irrevocable.

10. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

11. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

12. I say that my wishes in respect of the matters referred to in paragraph 10above are as follows:

(i) I do/I do not wish to be heard on the application for the adoptionorder; (*d)

(ii) I do/I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*e)

13. I understand that this affidavit may be used as evidence that I consent tothe adoption order being made.

Signature.............................................................................

Sworn at ............................................................................................ in the county of............................................................. on this................day of.........................20.........

before me and I know the deponent (or I know......................................................,

who certifies to me that (s)he knows the deponent).

Signature......................................................................................

Description (*f)........................................................................................

(*a), (*b), (*d) and (*e) Delete words which do not apply. All deletions must beinitialled by the deponent and by the person before whom the affidavit is sworn.

(*c) Delete entire line if it does not apply. The deletion must be initialled bythe deponent and by the person before whom the affidavit is sworn.

8 [519]

(*f) If the affidavit is being sworn in the State, it should be sworn before aCommissioner for Oaths; if it is being sworn elsewhere, it should be swornbefore a Notary Public or other person duly authorised to administer oaths.

[519] 9

The Adoption Authority of Ireland

Form 3

DECLARATION OF CONSENT TO ADOPTION

(For use by a mother where the identity of the applicant(s) is known to her)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

spinster/married/divorced/widow (*a), aged eighteen years and upwards (or, ifunder eighteen, aged............................ years), do solemnly and sincerely declarethat:

1. I am aware that an application is about to be made or has been made by

. ...................................................................................................................... (names(s))

of ................................................................................................................... , (address)

for an adoption order in respect of the said child.

2. I am the mother of the said child.

3. I did / did not marry the father of the said child. (*b)

4. I am / I am not the sole guardian of the said child. (*c)

5. The father has / has not been appointed a guardian of the said child pursu-ant to a court order or otherwise. (*d)

6. To the best of my knowledge and belief the father has / has not institutedproceedings in relation to access to, guardianship or custody of, the said child.(*e)

7. The said child is not less than six weeks old, having been born on the..................................... day of ................................... 20 ......

8. I know that the religion of the male applicant is .............................................and that the religion of the female applicant is ........................................................

9. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties with

10 [519]

respect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

10. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

11. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

12. I have been informed and I understand that this consent may be with-drawn, at any time before the making of the adoption order, by my so informingthe Adoption Authority of Ireland, Shelbourne House, Shelbourne Road,Dublin 4, and that on the making of the adoption order my consent becomesirrevocable.

13. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

14. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

15. I say that my wishes in respect of the matters referred to in paragraph 13above are as follows:

(i) I do / I do not wish to be heard on the application for the adoptionorder; (*f)

(ii) I do / I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*g)

15. I understand that this declaration may be used as evidence that I consentto the adoption order being made.

I make this solemn declaration conscientiously believing the same to be trueand by virtue of the Statutory Declarations Act 1938.

Signature.......................................................................

Declared before me by............................................... (name of declarant), who ispersonally known to me (or who is identified to me by.........................., who ispersonally known to me), at

..............................................................................................

on this............................................. day of...........................................20.....

[519] 11

Signature........................................................................

Description (*h) .............................................................................................................

(*a), (*b), (*c), (*d), (*e), (*f) and (*g): Delete words which do not apply. Alldeletions must be initialled by the declarant and by the person before whom thedeclaration is made.

(*h) This declaration may be made before a Notary Public, a Commissioner forOaths, a Peace Commissioner or other person authorised by law to take andreceive statutory declarations.

12 [519]

Form 4

The Adoption Authority of Ireland

DECLARATION OF CONSENT TO ADOPTION

(For use by a person other than the mother where the identity of the applicant(s)is known to the consenting party)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

bachelor/spinster/married/divorced/widow/widower (*a), aged eighteen yearsand upwards (or, if under eighteen, aged............................ years), do solemnlyand sincerely declare that:

1. I am aware that an application is about to be made or has been made by

........................................................................................................................(names(s))

of...................................................................................................................... (address)

for an adoption order in respect of the said child.

2. I am the father of the said child / a guardian of the said child/ a personhaving charge of or control over the said child. (*b)

3. I am the father of the said child and I married the mother of the said child.(*c)

4. The said child is not less than six weeks old, having been born on the...........-day of...................................., 20.....

5. I know that the religion of the male applicant is .............................................and that the religion of the female applicant is ........................................................

6. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

7. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

[519] 13

8. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

9. I have been informed and I understand that this consent may be withdrawn,at any time before the making of the adoption order, by my so informing theAdoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4,and that on the making of the adoption order my consent becomes irrevocable.

10. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

11. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

12. I say that my wishes in respect of the matters referred to in paragraph 10above are as follows:

(i) I do/I do not wish to be heard on the application for the adoptionorder; (*d)

(ii) I do/I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*e)

13. I understand that this declaration may be used as evidence that I consentto the adoption order being made.

I make this solemn declaration conscientiously believing the same to be trueand by virtue of the Statutory Declarations Act 1938.

Signature................................................................

Declared before me by............................................... (name of declarant), who ispersonally known to me (or who is identified to me by.........................................,who is personally known to me), at

........................................................................................

on this............................................. day of...........................................20.....

Signature.................................................................

Description (*f)..............................................................................................

(*a), (*b), (*d) and (*e): Delete words which do not apply. All deletions mustbe initialled by the declarant and by the person before whom the declarationis made.

14 [519]

(*c) Delete entire line if it does not apply. The deletion must be initialled bythe declarant and by the person before whom the declaration is made.

(*f) This declaration may be made before a Notary Public, a Commissioner forOaths, a Peace Commissioner or other person authorised by law to take andreceive statutory declarations.

[519] 15

Form 5

The Adoption Authority of Ireland

AFFIDAVIT OF CONSENT TO ADOPTION

(For use by a mother where the identity of the applicant(s) is not known to her)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

spinster/married/divorced/widow (*a), aged eighteen years and upwards (or, ifunder eighteen, aged .......................... years), make oath and say as follows:

1. I have been informed and I believe that an application has been madeunder serial number ........................... (*b) for an adoption order in respect ofthe said child.

2. I am the mother of the said child.

3. I did / I did not marry the father of the said child. (*c)

4. I am / I am not the sole guardian of the said child. (*d)

5. The father has / has not been appointed a guardian of the said child pursu-ant to a court order or otherwise. (*e)

6. To the best of my knowledge and belief the father has / has not institutedproceedings in relation to access to, or guardianship or custody of, the said child.(*f)

7. The said child is not less than six weeks old, having been born on the............... day of ...................20 ....

8. I know that the religion of the male applicant is ..............................................and that the religion of the female applicant is .........................................................

9. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

16 [519]

10. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

11. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

12. I have been informed and I understand that this consent may be with-drawn, at any time before the making of the adoption order, by my so informingthe Adoption Authority of Ireland, Shelbourne House, Shelbourne Road,Dublin 4, and that on the making of the adoption order my consent becomesirrevocable.

13. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

14. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

15. I say that my wishes in respect of the matters referred to in paragraph 13above are as follows:

(i) I do / I do not wish to be heard on the application for the adoptionorder; (*g)

(ii) I do / I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*h)

16. I understand that this affidavit may be used as evidence that I consent tothe adoption order being made.

Signature.....................................................................

Sworn at ............................................................................................ in the county of............................................................. on this................day of.........................20.........

before me and I know the deponent (or I know......................................................who certifies to me that (s)he knows the deponent).

Signature......................................................................................

Description (*i)..............................................................

(*a), (*c), (*d), (*e), (*f), (*g) and (*h): Delete words which do not apply. Alldeletions must be initialled by the deponent and by the person before whomthe affidavit is sworn.

[519] 17

(*b) Where the identity of the applicant(s) is not known to the consenting party,the applicant(s) should request the Authority to assign a serial number to theapplication, and this number should be inserted here.

(*i) If the affidavit is being sworn in the State, it should be sworn before aCommissioner for Oaths; if it is being sworn elsewhere, it should be swornbefore a Notary Public or other person duly authorised to administer oaths.

18 [519]

Form 6

The Adoption Authority of Ireland

AFFIDAVIT OF CONSENT TO ADOPTION

(For use by a person other than the mother where the identity of the applicant(s)is not known to the consenting party)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

bachelor/spinster/married/divorced/widow/widower (*a), aged eighteen yearsand upwards (or, if under eighteen, aged.......................... years), make oath andsay as follows:

1. I have been informed and I believe that an application has been madeunder serial number........................... (*b) for an adoption order in respect of thesaid child.

2. I am the father of the said child/a guardian of the said child/a person havingcharge of or control over the said child. (*c)

3. I am the father of the said child and I married the mother of the said child.(*d)

4. The said child is not less than six weeks old, having been born on the............... day of ..........................20..........

5. I know that the religion of the male applicant is .............................................

and that the religion of the female applicant is ........................................................

6. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

7. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

8. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

[519] 19

9. I have been informed and I understand that this consent may be withdrawn,at any time before the making of the adoption order, by my so informing theAdoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4,and that on the making of the adoption order my consent becomes irrevocable.

10. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

11. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

12. I say that my wishes in respect of the matters referred to in paragraph 10above are as follows:

(i) I do / I do not wish to be heard on the application for the adoptionorder; (*e)

(ii) I do / I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*f)

13. I understand that this affidavit may be used as evidence that I consent tothe adoption order being made.

Signature........................................................................

Sworn at ............................................................................................ in the county of............................................................. on this................day of.........................20.........

before me and I know the deponent (or I know......................................................,

who certifies to me that (s)he knows the deponent).

Signature......................................................................................

Description (*g)..............................................................

(*a), (*c), (*e) and (*f): Delete words which do not apply. All deletions must beinitialled by the deponent and by the person before whom the affidavit is sworn.

(*b) Where the identity of the applicant(s) is not known to the consenting party,the applicant(s) should request the Authority to assign a serial number to theapplication, and this number should be inserted here.

(*d) Delete entire line if it does not apply. The deletion must be initialled bythe deponent and by the person before whom the affidavit is sworn.

20 [519]

(*g) If the affidavit is being sworn in the State, it should be sworn before aCommissioner for Oaths; if it is being sworn elsewhere, it should be swornbefore a Notary Public or other person duly authorised to administer oaths.

[519] 21

Form 7

The Adoption Authority of Ireland

DECLARATION OF CONSENT TO ADOPTION

(For use by a mother where the identity of the applicant(s) is not known to her)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

spinster/married/divorced/widow (*a), aged eighteen years and upwards (or, ifunder eighteen, aged......years), do solemnly and sincerely declare that:

1. I have been informed and I believe that an application has been madeunder serial number........................... (*b) for an adoption order in respect of thesaid child.

2. I am the mother of the said child.

3. I did / I did not marry the father of the said child. (*c)

4. I am / I am not the sole guardian of the said child. (*d)

5. The father has / has not been appointed a guardian of the said child pursu-ant to a court order or otherwise. (*e)

6. To the best of my knowledge and belief the father has / has not institutedproceedings in relation to access to, or guardianship or custody of, the said child.(*f)

7. The said child is not less than six weeks old, having been born on the................. day of ....................20 ....

8. I know that the religion of the male applicant is .............................................and that the religion of the female applicant is ........................................................

9. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

22 [519]

10. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

11. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

12. I have been informed and I understand that this consent may be with-drawn, at any time before the making of the adoption order, by my so informingthe Adoption Authority of Ireland, Shelbourne House, Shelbourne Road,Dublin 4, and that on the making of the adoption order my consent becomesirrevocable.

13. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

14. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

15. I say that my wishes in respect of the matters referred to in paragraph 13above are as follows:

(i) I do / I do not wish to be heard on the application for the adoptionorder; (*g)

(ii) I do / I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*h)

16. I understand that this declaration may be used as evidence that I consentto the adoption order being made.

I make this solemn declaration conscientiously believing the same to be trueand by virtue of the Statutory Declarations Act 1938.

Signature.....................................................................

Declared before me by............................................... (name of declarant), who ispersonally known to me (or who is identified to me by...................................., whois personally known to me), at

..........................................................................................................................................

on this...... day of...........................................20.......

Signature..........................................................................................................................

Description (*i)..............................................................

[519] 23

(*a), (*c), (*d), (*e), (*f), (*g) and (*h) Delete words which do not apply. Alldeletions must be initialled by the declarant and by the person before whom thedeclaration is made.

(*b) Where the identity of the applicant(s) is not known to the consenting party,the applicant(s) should request the Authority to assign a serial number to theapplication, and this number should be inserted here.

(*i) This declaration may be made before a Notary Public, a Commissioner forOaths, a Peace Commissioner or other person authorised by law to take andreceive statutory declarations.

24 [519]

Form 8

The Adoption Authority of Ireland

DECLARATION OF CONSENT TO ADOPTION

(For use by a person other than the mother where the identity of the applicant(s)is not known to the consenting party)

In the matter of an application for the adoption of .... ... ... ... ... ... ... ... ...... ...

(child’s full name)

I, ........................................................................................................................, (name)

of ......................................................................................................................................

........................................................................................................................ , (address)

bachelor/spinster/married/divorced/widow/widower (*a), aged eighteen yearsand upwards (or, if under eighteen, aged.......................... years), do solemnly andsincerely declare that:

1. I have been informed and I believe that an application has been madeunder serial number........................... (*b) for an adoption order in respect of thesaid child.

2. I am the father of the said child/a guardian of the said child/a person havingcharge of or control over the said child. (*c)

3. I am the father of the said child and I married the mother of the said child.(*d)

4. The said child is not less than six weeks old, having been born on the................. day of .......................20......

5. I know that the religion of the male applicant is .............................................

and that the religion of the female applicant is ........................................................

6. I understand that the nature and effect of an adoption order is that I shalllose all parental rights and that I shall be freed from all parental duties withrespect to the said child and that these rights and duties shall be transferred tothe adopter or adopters.

7. I have been informed and I understand that the Adoption Authority ofIreland may make an adoption order in respect of the said child at any timeafter the signing of this consent.

8. I hereby freely give my consent to the making of an adoption order inpursuance of the application referred to above.

[519] 25

9. I have been informed and I understand that this consent may be withdrawn,at any time before the making of the adoption order, by my so informing theAdoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4,and that on the making of the adoption order my consent becomes irrevocable.

10. I have been informed and I understand that I am entitled to be heard inperson or to be represented by counsel or solicitor on the application for theadoption order or otherwise to be consulted again in relation to the applicationand that I should indicate in writing to the Authority my wishes in this respect.I also understand that if I wish to be heard I will be informed of the date onwhich the Authority will hear me or my counsel or solicitor.

11. I have been informed and I understand that, despite any subsequent with-drawal of my consent, the High Court, on application, may, at its discretion,authorise the Adoption Authority to dispense with my consent.

12. I say that my wishes in respect of the matters referred to in paragraph 10above are as follows:

(i) I do / I do not wish to be heard on the application for the adoptionorder; (*e)

(ii) I do / I do not wish otherwise to be consulted again in relation tothe application for the adoption order. (*f)

13. I understand that this declaration may be used as evidence that I consentto the adoption order being made.

I make this solemn declaration conscientiously believing the same to be trueand by virtue of the Statutory Declarations Act 1938.

Signature........................................................................

Declared before me by............................................... (name of declarant), who ispersonally known to me (or who is identified to me by..............................., whois personally known to me), at

..........................................................................................................................................

on this ............................................. day of ...........................................20 .....

Signature.........................................................................

Description (*g) ..............................................................

(*a), (*c), (*e) and (*f): Delete words which do not apply. All deletions mustbe initialled by the declarant and by the person before whom the declarationis made.

(*b) Where the identity of the applicant(s) is not known to the consenting party,the applicant(s) should request the Authority to assign a serial number to theapplication and this number should be inserted here.

26 [519]

(*d) Delete entire line if it does not apply. The deletion must be initialled bythe declarant and by the person before whom the declaration is made.

(*g) This declaration may be made before a Notary Public, a Commissioner forOaths, a Peace Commissioner or other person authorised by law to take andreceive statutory declarations.

GIVEN under my hand,2 November 2010.

BARRY ANDREWS,Minister of State at the Department of Health and Children.

[519] 27

EXPLANATORY NOTE

(This Note is not part of the Instrument and does not purport to be a legalinterpretation.)

These regulations set out the prescribed consent forms under section 26 ofthe Adoption Act 2010 (No. 21 of 2010).

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FOILSEACHÁIN RIALTAIS, AN RANNÓG POST-TRÁCHTA,AONAD 20 PÁIRC MIONDÍOLA COIS LOCHA, CLÁR CHLAINNE MHUIRIS,

CONTAE MHAIGH EO,(Teil: 01 - 6476834 nó 1890 213434; Fax: 094 - 9378964 nó 01 - 6476843)

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