Acknowledgment

Acknowledgment

I represent that the information contained in all of the documents I have signed at the request of the adoptive parents or my attorney or the adoption agency I am working with, including the Birth Mother’s Social & Family History, Birth Mother’s Medical History, and Birth Mother’s Adoption Plan are true and accurate. I acknowledge that the adoptive parent(s) and other parties will rely on this information in making a determination to proceed with the anticipated adoption and the Court will rely on this information during the adoption related proceedings. I hereby waive any claim of privilege and agree that the information contained in these forms and any information provided by myself, my counselors, and my physicians may be given to the adoptive parent(s), their agency, their attorney, other attorneys, and other state officials, including law enforcement authorities, through all communication medium.

I further understand that I am entering into a plan that places children for adoption and any false statement may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties under the law. I also understand that working simultaneously with more than one attorney, agency or adoptive couple may subject me to criminal and/or civil penalties under the law.

In my written and verbal communications in connection with my adoption plan, I have not provided any false or misleading information of any kind including information concerning myself, the biological mother, or the background or medical history of my family.

I hereby authorize my attorney, the adoptive parent(s), their agency, their attorney, other attorneys, and other state officials, including law enforcement authorities to make inquiry about the truthfulness of the statements made in this document and the circumstances if this placement with other medical, legal and adoption professionals through all communication medium.

Under penalties of perjury, I declare that I have read the foregoing and the facts stated in the documents named herein are true.

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