S.I. No. 170/1990 - Adoption Rules, 1990.

S.I. No. 170 of 1990.

ADOPTION RULES, 1990.

An Bord Uchtala, with the consent of the Minister for Health and in exercise of the powers conferred on it by section 5 of the Adoption Act, 1952 (No. 25 of 1952), hereby makes the following rules:—

1. These rules may be cited as the Adoption Rules, 1990.

2. The Adoption Rules, 1976 ( S.I. No. 216 of 1976 ), and the Adoption Rules, 1984 ( S.I. No. 134 of 1984 ), are hereby revoked.

3. The Adoption Rules 1988 ( S.I. No. 304 of 1988 ), the Adoption (No. 2) Rules, 1988 ( S.I. No. 329 of 1988 ) and these rules shall be construed as one and may be cited together as the Adoption Rules, 1988 to 1990.

4. In these rules—

"the Acts" means the Adoption Acts, 1952 to 1988:

"the Board" means An Bord Uchtala;

"the Registrar" means the Registrar of the Board.

"adoption agency" means a registered adoption society or a health board.

5. Each of the forms set out in the Schedule shall be used in the case and manner indicated by the form.

6. Notwithstanding the revocation of the Adoption Rules, 1976, and the Adoption Rules, 1984, the forms prescribed in those Rules may continue to be used to the extent permitted by the Board.

7. The Board may require an applicant for an adoption order to submit medical evidence of the state of his health.

8. The Board may require the person or body that placed a child for adoption to submit medical evidence of the state of the child's health.

9. The Board may require any statement in a prescribed form to be verified by oral or other evidence.

10. The Registrar shall give to every applicant for an adoption order at least ten days' notice in writing or such shorter notice as may be accepted by the applicant of the date, hour and place of hearing of the application.

11. The Registrar shall give to every person whose consent to the making of an adoption order is required (other than such person as has indicated that he does not wish to be informed of the date on which the Board would hear him or his counsel or solicitor on the application for the adoption order) at least ten days notice in writing of the date, hour and place at which the Board will hear him or his counsel or solicitor on the application for the order.

12. The Registrar shall give to every person summoned to attend before the Board as a witness at least ten days notice in writing of the date, hour and place at which he is to attend before the Board.

13. These rules shall come into operation three months after their signing.

GIVEN under the Official Seal of the Board this 6th day of July, 1990.

VIRGINIA ROCHFORD,

Chairman.

The Minister for Health hereby consents to the foregoing rules.

GIVEN under the Official Seal of the Minister for Health this 6th day of July 1990.

RORY O'HANLON,

Minister for Health.

SCHEDULE.

Form 1.

APPLICATION FOR ADOPTION ORDER.

PART 1 —SECTION A.

(To be completed in all cases where the application is being made by a married couple)

We, the undersigned, being a married couple living together, desire to adopt the child named or described in this application form. We understand that if an adoption order is granted to us in respect of the child, we shall be fully responsible for the child's upbringing, as if the child were born to us in lawful wedlock and we voluntarily undertake to discharge that responsibility as far as we are able. We have not received or made, or agreed to receive or make, any payment whatsoever in consideration of the adoption of this child.*

	Husband's Signature ............................................................ ...
	Wife's Signature............................................................ ............
Date............................................................ .................................

*Payments made or received in respect of the child's maintenance or solicitors' remuneration for professional services are not referred to here.

PART 1 — SECTION B.

(To be completed only where the application is being made by one person)

I, the undersigned person, being the mother of the child/the natural father of the child/a relative* of the child/a widow/widower (Delete inapplicable words).

desire to adopt the child named or described in this application form. I understand that if an adoption order is granted to me in respect of the child, I shall be fully responsible for the child's upbringing as if the child were born to me in lawful wedlock and I voluntarily undertake to discharge that responsibility as far as I am able. I have not received or made, or agreed to receive or make, any payment whatsoever in consideration of the adoption of this child.**

	Applicant's Signature .................................................
Date ............................................................ ...................

*"relative" here means grandparent, brother, sister, uncle or aunt, whether of the whole blood, of the half blood, or by affinity, relationship to a child born outside marriage being traced through the mother only.

**Payments made or received in respect of the child's maintenance or solicitors' remuneration for professional services are not referred to here.

PART 2 —SECTION A.

(To be completed in every application.)

(If the application is being made by a married couple, the particulars given in this section should be those relating to the Husband only).

1.	Husband's/Applicant's name. (Delete "husband's" or "applicant's", whichever does not apply)
	(Block letters)............................................................ ............................................................ ......................................
2.	Address (Block letters)............................................................ ............................................................ .........
	............................................................ ............................................................ ...................................................
3.	Occupation............................................................ ............................................................ .............................
4.	Relationship (if any) to the child ............................................................ .....................................................
5.	Date of birth ............................................................ ............................................................ .........................
6.	Are you ordinarily resident in the State and, if so, since when?
	............................................................ ............................................................ ....................................................
7.	Religious denomination ............................................................ ............................................................ ........

PART 2 — SECTION B.

(This section to be completed ONLY where the application is being made by a married couple.)

(The particulars given in this section should be those relating to the wife only)

8.	Wife' name (Block letters) ............................................................ .........................................................
9.	Occupation............................................................ ............................................................ .......................
10.	Relationship (if any) to child ............................................................ .....................................................
11.	Date of birth............................................................ ............................................................ ......................................
12.	Are you ordinarily resident in the State and, if so, since when? ............................................................ ............................................................ ...............................................
13.	Religious denomination ............................................................ ............................................................ ...

PART 2— SECTION C.

(This section to be completed only where the application is being made by a married couple)

14.	Date and place of marriage............................................................ ...........................................................
15.	Did either of you have a previous marriage; if so, please give the date and place, and the date of death of spouse or the date and place of dissolution?
	............................................................ ............................................................ ..............................................
	............................................................ ............................................................ ...............................................
	............................................................ ............................................................ ................................................

PART 2 — SECTION D.

(To be completed in every application)

16.	Have you previously applied for an adoption order in respect of this or any other child and, if so, with what result?
	............................................................ ............................................................ ................................................
	............................................................ ............................................................ .................................................
17.	(a) Have you any children of your own; if so, please give names, dates of birth and present addresses?
	............................................................ ............................................................ .................................................
	............................................................ ............................................................ .................................................
	............................................................ ............................................................ .................................................
	(b) Have you any other children in your care; if so, please give names and dates of birth?
	............................................................ ............................................................ .................................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ..................................................
18.	Christian name or first name of child to whom this application refers (Block letters)
	............................................................ ............................................................ ..................................................
19.	Sex ............................................................ ............................................................ .............................................
20.	Date of birth............................................................ ............................................................ ..........................
21.	Name and address of person or body from whom you got the child .................................................
	............................................................ ............................................................ ................................................
	............................................................ ............................................................ ..................................................
22.	Date on which you took the child under your care............................................................ ......................
	............................................................ ............................................................ ...................................................
23.	Please give the names and addresses of two or more persons not related to you to whom reference may be made by the Board (Block letters)
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ....................................................

Note: The Board may require you to submit medical evidence of your state of health before coming to a decision on your application.

Form 2A.

BACKGROUND REPORT ON CHILD AND NATURAL PARENTS.

(To be completed by adoption agency for each application)

PART I.

THE CHILD

1.	Name ............................................................ .................. Sex............................................................ .............
2.	Date of Birth............................................................ ............................................................ ............................
3.	Was the child born
	(a) Outside Marriage?............................................................ ............................................................ ..........
	(b) Within marriage? ............................................................ ............................................................ .............
	(c) Of an extra-marital relationship? ............................................................ .................................................
4.	Did the child's natural parents marry each other after the birth?
	............................................................ ............................................................ ....................................................
5.	Pre-placement history of child ............................................................ ..........................................................
	............................................................ ............................................................ ....................................................
	............................................................ ............................................................ .....................................................
6.	If child was more than four months old at date of placement, please state reason(s) for delay ............
	............................................................ ............................................................ .......................................................
	............................................................ ............................................................ ......................................................
	............................................................ ............................................................ ......................................................

PART 2.

THE NATURAL MOTHER

7.	Name and Address............................................................ ............................................................ .............
	............................................................ ............................................................ ...............................................
8.	Date of birth, or if unknown, approximate age ............................................................ ...........................
9.	Religion (if any) ............................................................ ............................................................ ....................
10.	Marital Status ............................................................ ............................................................ ........................
11.	Date and place of marriage (if applicable) ............................................................ ....................................
	............................................................ ............................................................ ................................................
12.	Level of Education: Primary/Secondary/Third Level? ............................................................ ..............
	............................................................ ............................................................ ..............................................
13.	Occupation............................................................ ............................................................ ............................
14.	Is she currently in employment? ............................................................ ....................................................
15.	Community Care Area of mother at time of initial contact with agency
	............................................................ ............................................................ ..............................................
16.	Date of initial contact with agency ............................................................ .............................................
17.	By whom was the mother counselled? ............................................................ ...........................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ..................................................
18.	Reason(s) for placing child for adoption ............................................................ ....................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ...................................................
19.	Did she meet the prospective adopters? ............................................................ ......................................
20.	Has the mother other children? If so, please state number and whether they are with her, adopted or elsewhere............................................................ ............................................................ .............................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ...................................................
21.	Please give particulars of any known history of psychiatric or hereditary illness in the natural mother or any member of her family ............................................................ ...............................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ...................................................

PART 3.

(To be completed only where the natural mother is under eighteen years of age)

22.	How was the mother referred to the agency? ............................................................ ............................
	............................................................ ............................................................ ................................................
23.	Were her parents aware of the pregnancy? If so, what was their attitude? ........................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ...................................................
24.	(a) Were her parents interviewed by the agency?
	............................................................ ............................................................ .................................................
	(b) If so, was the natural mother interviewed separately?
	............................................................ ............................................................ ...................................................

PART 4.

THE NATURAL FATHER

25.	Is his name known?............................................................ ............................................................ ............
26.	Is he registered as the father on the child's birth certificate?
	............................................................ ............................................................ .................................................
27.	Is he married? ............................................................ ............................................................ ......................
28.	Was he interviewed by the agency? ............................................................ .............................................
29.	Is his relationship with the natural mother continuing or has it terminated? .....................................
30.	What is his attitude to the proposed adoption?............................................................ .......................
	............................................................ ............................................................ ................................................
	............................................................ ............................................................ ................................................
31.	Has he been appointed a guardian of the child pursuant to a court order or otherwise? ..................
32.	Has the agency or the mother been given any indication that he intends applying to court for legal rights in relation to the child? If so, please give particulars ............................................................ .....
	............................................................ ............................................................ ...............................................
33.	Has the father other children? If so, please state number and whether they are with him, adopted or elsewhere ............................................................ ............................................................ ............................
	............................................................ ............................................................ ..............................................
	............................................................ ............................................................ ...............................................
34.	Please give particulars of any known history of psychiatric or hereditary illness in the natural father or any member of his family
	............................................................ ............................................................ ...............................................
	............................................................ ............................................................ ...............................................

PART 5.

35.	Please set out below any other information on the child's natural background which might have a bearing on the application.
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ....................................................
	............................................................ ............................................................ .....................................................
	............................................................ ............................................................ ......................................................
	............................................................ ............................................................ ......................................................
		Signed............................................................ .....................................
		Description ............................................................ .............................
		Adoption Agency ............................................................ .................
Date ............................................................ .......................................

Form 2B.

BACKGROUND REPORT ON CHILD AND NATURAL PARENTS.

(To be completed by applicant(s) where the adoption was arranged otherwise than by a registered adoption society or health board)

PART 1.

THE CHILD

1.	Name ............................................................ ......................... Sex ............................................................ ......
2.	Date of Birth ............................................................ ............................................................ ..........................
3.	Was the child born
	(a) Outside marriage? ............................................................ ............................................................ ...........
	(b) Within marriage? ............................................................ ............................................................ .............
	(c) Of an extra-marital relationship? ............................................................ ................................................
4.	Did the child's natural parents marry each other after the birth? ..........................................................
5.	Pre-placement history of child ............................................................ ..........................................................
	............................................................ ............................................................ .....................................................
	............................................................ ............................................................ ....................................................
6.	Has the mother other children? If so, please state number and whether they are with her, adopted or elsewhere.
	............................................................ ............................................................ .....................................................
	............................................................ ............................................................ ..................................................

PART 2.

THE NATURAL MOTHER

7.	Name and Address............................................................ ............................................................ .................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ...................................................
8.	Date of birth, or if unknown, approximate age ............................................................ ...........................
9.	Religion ............................................................ ............................................................ ...................................
10.	Marital Status ............................................................ ............................................................ ......................
11.	Date and place of marriage (if applicable)............................................................ ....................................
	............................................................ ............................................................ ................................................
12.	Level of Education: Primary/Secondary/Third Level?............................................................ ................
	............................................................ ............................................................ ................................................
13.	Occupation ............................................................ ............................................................ ..........................
14.	Is she currently in employment? ............................................................ ...................................................
15.	Reason(s) for placing child for adoption ............................................................ ....................................
	............................................................ ............................................................ .................................................
	............................................................ ............................................................ ..................................................
16.	How did she meet the prospective adopters?............................................................ ................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ..................................................

PART 3.

THE NATURAL FATHER

17.	Is his name known? ............................................................ ............................................................ ..............
18.	Is he registered as the father on the child's birth certificate?............................................................ ......
	............................................................ ............................................................ ...................................................
19.	Is he married? ............................................................ ............................................................ ..........................
20.	Is his relationship with the natural mother continuing or has it terminated?........................................
21.	What is his attitude to the proposed adoption?............................................................ ............................
	............................................................ ............................................................ ...................................................
22.	Has he been appointed a guardian of the child pursuant to a court order or otherwise? ...................
23.	Has he given any indication that he intends applying to court for legal rights in relation to the child? If so, please give particulars.
	............................................................ ............................................................ ...................................................

PART 4.

24.	Please set out below any other information on the child's natural background which might have a bearing on the application.
	............................................................ ............................................................ ....................................................
	............................................................ ............................................................ ....................................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ...................................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ ..................................................
	............................................................ ............................................................ .................................................
		Signature of female applicant ............................................................ .
		Signature of male applicant ............................................................ .....
Date ............................................................ ..............................................

Form 3A.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child ............................................................ .......
............................................................ ............................................................ ............................................................
I, ............................................................ ........................ (name) of ............................................................ ..............
............................................................ ............................................................ .......................................... (address) Spinster/Married/Divorced/Widow (a) aged eighteen years and upwards (or, if under 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 ..................................
............................................................ ............................................................ .........................................
of ............................................................ ............................................................ .................................. 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. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (c)
5. To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (d)
6. The said child is not less than six weeks old, having been born on the ............day of ......... 19...
7. I know that the religion of the male applicant is............................................................ ......... and that the religion of the female applicant is ............................................................ ...........
8. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
9. I have been informed and I understand that an Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
10. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above.
11. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of an adoption order my consent becomes irrevocable.
12. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
13. I say that my wishes in respect of the matters referred to in paragraph 12 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (e)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (f)
14. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature ............................................................ ............................
Sworn at ............................................................ ............ in the county of ............................................................ .
on this .................. day of............................................................ ............................................... 19.........
before me, and I know the deponent (or and I know............................................................ ...............................
who certifies to me that he knows the deponent)
	Signature ............................................................ ..........................
Description (g) ............................................................ ................
(a), (b), (c), (d), (e) and (f) Delete words which do not apply. All deletions must be initialled by the deponent and by the person before whom the affidavit is sworn.
(g) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 3B.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child ............................................................ ......
I, ............................................................ ............................................ (name) of ......................................................
............................................................ ............................................................ .................................................(address)
Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years and upwards (or, if under 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 ................................... ............................................................ ............................................................ .............................................. of............................................................ ............................................................ ....................... 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 person having 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 .............., 19........
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 shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
7. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
8. I hereby freely give my consent to the making of an adoption order in pursuance 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 informing An Bord Uchtala, Hawkins House, Dublin 2, 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 in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
11. I say that my wishes in respect of the matters referred to in paragraph 10 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (d)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (e)
12. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature ............................................................ .................
Sworn at ...................................... in the county of ............................................ on this ......................... day of................................ 19 .................................................. before me, and I know the deponent (or and I know ............................................................ ................ who certifies to me that he knows the deponent).
	Signature............................................................ ....................................
Description (f)............................................................ ............................
(a), (b), (c), (d) and (e) Delete words which do not apply. All deletions must be initialled by the deponent and by the person before whom the affidavit is sworn.
(f) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 3C.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child ............................................................ ......
............................................................ ............................................................ ............................................................ .
I, ............................................................ ................................... (name) of ............................................................ ....
............................................................ ............................................................ ............................................ (address)
Spinster/Married/Divorced/Widow/(a) aged eighteen years and upwards (or, if under Eighteen, aged ............................ years), do solemnly and sincerely declare that:—
1. I am aware that an application is about to be made or has been made by ..................................... ............................................................ ............................................................ ............................................... of............................................................ ............................................................ ............................................ 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. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (c)
5. To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child.(d)
6. The said child is not less than six weeks old, having been born on the .....................................
day of ................................... 19........................
7. I know that the religion of the male applicant is............................................................ ..................
and that the religion of the female applicant is............................................................ .....................
8. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
9. I have been informed and I understand that An Board Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
10. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above.
11. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
12. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
13. I say that my wishes in respect of the matters referred to in paragraph 12 above are as follows:—–
(i) I do/I do not wish to be heard on the application for the adoption order. (e)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (f)
14. I understand that this declaration may be used as evidence that I consent to the adoption order being made, and I made this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature ............................................................ ....................
Declared before me, by ............................................... (name of declarant) who is personally known to me (or who is identified to me by)
............................................................ ............................................................ ............................................
who is personally known to me), at............................................................ ...........................................
............................................................ ............................................................ .............................................
on this ............................................. day of...........................................19...............................................
	Signature............................................................ .............................................
Description (g) ............................................................ ..................................
(a), (b), (c), (d), (e) and (f) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(g) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 3D.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child............................................................ ...................
............................................................ ............................................................ ............................................................ .....
I, ............................................................ ........................................ (name) of ............................................................ ..
............................................................ ............................................................ ............................................... (address)
Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years and upwards (or, if under eighteen, aged ....................................................... years), do solemnly and sincerely declare that:—
1. I am aware that an application is about to be made or has been made by.......................................
............................................................ ............................................................ ...........................................
of............................................................ ............................................................ ...................................... ............................................................ ............................................................ ..........................................
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 person having 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 ............................................................ .. 19............................................................ .............
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 shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
7. I have been informed and I understand that an Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
8. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above.
9. I have been informed and 1 understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, 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 in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
11. I say that my wishes in respect of the matters referred to in paragraph 10 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (d)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (e)
12. I understand that this declaration may be used as evidence that I consent to the adoption order being made, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature ............................................................ ...........................
Declared before me, by ............................................... (name of declarant) who is personally known to me (or who is identified to me by ............................................................ ........................
who is personally known to me), at............................................................ ................................
............................................................ ............................................................ .........................................
on this ...............................day of .......................................... 19............
	Signature............................................................ ..................................................
	Description (f)............................................................ ........................................
(a), (b), (c), (d) and (e) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(f) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 4A.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child............................................................ ................
............................................................ ............................................................ ............................................................
I, ............................................................ ................................ (name) of ............................................................ ......
............................................................ ............................................................ ..............................................(address)
Spinster/Married/Divorced/Widow (a) aged eighteen years and upwards (or, if under eighteen, aged .......................... years), make oath and say as follows:—
1. I have been informed and I believe that an application has been made under serial number ........................... (b) 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 child. (c)
4. I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (d)
5. To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child.(e)
6. The said child is not less than six weeks old, having been born on the ..................................... day of ............................................................ ............. 19.................
7. I know that the religion of the male applicant is ............................................................ ..................
and that the religion of the female applicant is............................................................ ....................
8. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
9. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
10. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above.
11. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
12. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
13. I say that my wishes in respect of the matters refered to in paragraph 12 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (f)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (g)
14. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature............................................................ .........
Sworn at ............................................................ .... in the county of ......................................................... on this .................. day of ............................................................ ...................................... 19 ................ before me and I know the deponent (or and I know............................................................ ..........
............................................................ ............................................................ ........................................
who certifies to me that he knows the deponent).
	Signature............................................................ ...........
	Description (h)............................................................ ..
(a), (c), (d), (e), (f) and (g) Delete words which do not apply. All deletions must be initialled 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 Board to assign a serial number to the application and this number should be inserted here.
(h) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 4B.

CONSENT TO ADOPTION.

(For use by persons other than 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 the child ............................................................ ....................
............................................................ ............................................................ ............................................................ .....
I, ............................................................ ....................................... (name) of ............................................................ ...
............................................................ ............................................................ .................................................. (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years and upwards (or, if under eighteen, aged ............................. years), make oath and say as follows:—
1. I have been informed and I believe that an application has been made under serial number ...................... (b) 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 person having charge 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 ............... 19.............
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 shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
7. I have been informed and I understand that an Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
8. I hereby freely give my consent to the making of an adoption order in pursuance 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 informing An Bord Uchtala, Hawkins House, Dublin 2, 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 in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
11. I say that my wishes in respect of the matters referred to in paragraph 10 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (e)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (f)
12. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature............................................................ ............
Sworn at ........................................................... in the county of ............................................................ .
on this ........................ day of ............................................................ ................................... 19..................
before me, and I know the deponent (or and I know ............................................................ ..............
............................................................ ............................................................ ...........................................
who certifies to me that he knows the deponent).
	Signature ............................................................ ..........
	Description (g) ............................................................ .
(a), (c), (d), (e) and (f) Delete words which do not apply. All deletions must be initialled 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 Board to assign a serial number to the application and this number should be inserted here.
(g) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 4C.

CONSENT TO ADOPTION.

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

In the matter of an application for the adoption of the child ............................................................ ..........................
............................................................ ............................................................ ............................................................ ...........
I, ............................................................ .................................................. (name) of ..........................................................
............................................................ ............................................................ .................................................... (address) Spinster/Married/Divorced/Widow (a) aged eighteen years and upwards (or, if under eighteen, aged .................... years), do solemnly and sincerely declare that:—
1. I have been informed and 1 believe that an application has been made under serial number ................... (b) 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. (c)
4. I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (d)
5. To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (e)
6. The said child is not less than six weeks old, having been born on the ............. day of .......... 19.................
7. I know that the religion of the male applicant is ............................................................ ...........................
and that the religion of the female applicant is ............................................................ ..........................
8. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
9. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
10. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above.
11. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
12. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
13. I say that my wishes in respect of the matters referred to in paragraph 12 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (f)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (g)
14. I understand that this declaration may be used as evidence that I consent to the adoption order being made and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature ............................................................ ...............
Declared before me, by ............................................................ ........................................ (name of declarant) who is personally known to me (or who is identified to me by........................................
who is personally known to me), at ............................................................ ..............................................
on this ......................................................... day of ............................................................ ..... 19.................
		Signature ............................................................ ...........
		Description (h) ............................................................ ..
(a), (c), (d), (e), (f) and (g) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(b) Where the identity of the applicant(s) is not known to the consenting party, the applicant(s) should request the Board to assign a serial number to the application and this number should be inserted here.
(h) This declaration may be made before a notary public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 4D.

CONSENT TO ADOPTION.

(For use by persons other than 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 the child ............................................................ ....................
............................................................ ............................................................ ............................................................ .....
I, ............................................................ ............................................... (name) of........................................................
............................................................ ............................................................ ................................................ (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years
and upwards (or, if under eighteen, aged .................... years),do solemnly and sincerely declare that:—
1. I have been informed and I believe that an application has been made under serial number .............................. (b) 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 person having charge 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 ................. 19.............
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 shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter or adopters.
7. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
8. I hereby freely give my consent to the making of an adoption order in pursuance 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 informing An Bord Uchtala, Hawkins House, Dublin 2, 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 in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
11. I say that my wishes in respect of the matters referred to in paragraph 10 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (e)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (f)
12. I understand that this declaration may be used as evidence that I consent to the adoption order being made and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature............................................................ ...........
Declared before me, by ............................................... (name of declarant) who is personally known to me (or who is identified to me by............................................................ ............................................
who is personally known to me), at ............................................................ ..........................................
............................................................ ............................................................ ...........................................
on this ................................................... day of ............................................... 19.................................
	Signature............................................................ ..........
	Description (g)............................................................
(a), (c), (d), (e) and (f) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(b) Where the identity of the applicant(s) is not known to the consenting party the applicant(s) should request the Board to assign a serial number to the application and this number should be inserted here.
(g) This declaration may be made before a notary public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 5A.

CONSENT TO ADOPTION.

(For use where the applicant is a widow/widower and is known to the consenting party)

In the matter of an application for the adoption of the child ............................................................ ...............
............................................................ ............................................................ ............................................................
I, ............................................................ ................................................. (name) of...................................................
............................................................ ............................................................ ................................................. (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen
	years
and upwards (or, if under 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 .......................................
of ............................................................ ............................................................ .........................................
for an adoption order in respect of the said child.
2. I am the mother of the said child/the father of the said child/a guardian of the said child/a person having charge of or control over the said child. (b)
3. (To be completed by the mother only) I did/did not marry the father of the said child. (c)
4. (To be completed by the mother only) I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (d)
5. (To be completed by the mother only). To the best of my Knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (e)
6. I am the father of the said child and I married the mother of the said child. (f)
7. The said child is not less than six weeks old, having been born on the .................. day of ............. 19..........
8. I know that the religion of the applicant is ............................................................ ............................
9. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter.
10. I have been informed and I understand that an Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
11. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above and I know that the applicant is a widow/widower. (g)
12. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
13. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
14. I say that my wishes in respect of the matters referred to in paragraph 13 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (h)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (i)
15. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature............................................................ ............
Sworn at ............................................................ . in the county of ..........................................................
on this .................. day of ............................................................ .................................................. 19......
before me, and I know the deponent (or and I know............................................................ ............
............................................................ ............................................................ ........................................... who certifies to me that he knows the deponent).
	Signature............................................................ ...........
	Description (j) ............................................................ .
(a), (b), (c), (d), (e), (f), (g), (h) and (i) Delete words which do not apply. All deletions must be initialled by the deponent and by the person before whom the affidavit is sworn.
(j) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 5B.

CONSENT TO ADOPTION.

(For use where the applicant is a widow/widower and is not known to the consenting party)

In the matter of an application for the adoption of the child ............................................................ ................
............................................................ ............................................................ ............................................................ .
I, ............................................................ ........................................ (name) of...........................................................
............................................................ ............................................................ ............................................... (address)
Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years and upwards (or, if under eighteen, aged .......................... years), make oath and say as follows:—
1. I have been informed and I believe that an application has been made under serial number ........................................ (b) for an adoption order in respect of the said child.
2. I am the mother of the said child/the father of the said child/a guardian of the said child/a person having charge of or control over the said child. (c)
3. (To be completed by the mother only) I did/did not marry the father of the said child. (d)
4. (To be completed by the mother only) I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (e)
5. (To be completed by the mother only). To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (f)
6. I am the father of the said child and I married the mother of the said child. (g)
7. The child is not less than six weeks old, having been born on the ........ day of ................., 19..........
8. I know that the religion of the applicant is ............................................................ .........................
9. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter.
10. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
11. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above and I know that the applicant is a widow/widower. (h)
12. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
13. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
14. I say that my wishes in respect of the matters referred to in paragraph 13 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (i)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (j)
15. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.
	Signature............................................................ ............
Sworn at ............................................................ ............ in the county of ............................................
on this ........................... day of ............................................................ ....................... 19 ....................
before me, and I know the deponent (or and I know............................................................ ..............
............................................................ ............................................................ ..........................................
who certifies to me that he knows the deponent).
	Signature............................................................ ...........
	Description (k) ............................................................
(a), (c), (d), (e), (f), (g), (h), (i) and (j) Delete words which do not apply. All deletions must be initialled by the deponent and by the person before whom the affidavit is sworn.
(b) Where the identity of the applicant is not known to the consenting party the applicant should request the board to assign a serial number to the application and this number should be inserted here.
(k) If the affidavit is being sworn in the State it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere it should be sworn before a Notary Public or other person duly authorised to administer oaths.

Form 5C.

CONSENT TO ADOPTION.

(For use where the applicant is a widow/widower and is known to the consenting party).

In the matter of an application for the adoption of the child ............................................................ .................
............................................................ ............................................................ ............................................................ ..
I, ............................................................ ............................................ (name) of ........................................................
............................................................ ............................................................ ................................................ (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen
years	and
upwards (or, if under eighteen, aged ...................... years), do solemnly and sincerely declare that:—
1. I am aware that an application is about to be made or has been made by ..................................... of ............................................................ ............................................................ ........................................... for an adoption order in respect of the said child.
2. I am the mother of the said child/the father of the said child/a guardian of the said child/a person having charge of or control over the said child. (b)
3. (To be completed by the mother only). I did/did not marry the father of the said child. (c)
4. (To be completed by the mother only). I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (d)
5. (To be completed by the mother only). To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (e)
6. I am the father of the said child and I married the mother of the said child. (f)
7. The said child is not less than six weeks old, having been born on the ............. day of .................. 19...........
8. I know that the religion of the applicant is ............................................................ .............................
9. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter.
10. I have been informed and I understand that An Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
11. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above and I know that the applicant is a widow/widower. (g)
12. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
13. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing, I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
14. I say that my wishes in respect of the matters referred to in paragraph 13 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (h)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (i)
15. I understand that this declaration may be used as evidence that I consent to the adoption order being made and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature............................................................ ............
Declared before me, by ............................................... (name of declarant) who is personally known to me (or who is identified to me by............................................................ ..........................................
............................................................ ............................................................ ................................................
who is personally known to me), at ............................................................ .......................................
on this ............................................ day of ............................................................ ........ 19.............................
	Signature............................................................ .............
	Description (j)............................................................ .....
(a), (b), (c), (d), (e), (f), (g), (h) and (i) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(j) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 5D.

CONSENT TO ADOPTION.

(For use where the applicant is a widow/widower and is not known to the consenting party).

In the matter of an application for the adoption of the child ............................................................ .................
............................................................ ............................................................ ............................................................ ...
I, ............................................................ .................................................. (name) of....................................................
............................................................ ............................................................ ............................................... (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen
years and upwards (or, if under eighteen, aged ...................... years), do solemnly and sincerely declare that:—
1. I have been informed and believe that an application has been made under serial number ................................. (b) for an adoption order in respect of the said child.
2. I am the mother of the said child/the father of the said child/a guardian of the said child/a person having charge of or control over the said child. (c)
3. (To be completed by the mother only). I did/did not marry the father of the said child. (d)
4. (To be completed by the mother only). I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (e)
5. (To be completed by the mother only). To the best of my knowledge and belief the father has not instituted proceedings in relation to guardianship or custody of the said child. (f)
6. I am the father of the said child and I married the mother of the said child. (g)
7. The said child is not less than six weeks old, having been born on the ......... day of ............... 19.........
8. I know that the religion of the applicant is ............................................................ ...............................
9. I understand that the nature and effect of an adoption order is that I shall lose all parental rights and that I shall be freed from all parental duties with respect to the said child and that these rights and duties shall be transferred to the adopter.
10. I have been informed and I understand that an Bord Uchtala (Adoption Board) may make an adoption order in respect of the said child at any time after the signing of this consent.
11. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above and I know that the applicant is a widow/widower. (h)
12. I have been informed and I understand that this consent may be withdrawn at any time before the making of the adoption order, by informing An Bord Uchtala, Hawkins House, Dublin 2, and that on the making of the adoption order my consent becomes irrevocable.
13. I have been informed and I understand that I am entitled to be heard in person or to be represented by counsel or solicitor on the application for the adoption order or otherwise to be consulted again in relation to the application and that I should indicate my wishes in this respect in writing. I also understand that if I wish to be heard I will be informed of the date on which the Board will hear me or my counsel or solicitor.
14. I say that my wishes in respect of the matters referred to in paragraph 13 above are as follows:—
(i) I do/I do not wish to be heard on the application for the adoption order. (i)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (j)
15. I understand that this declaration may be used as evidence that I consent to the adoption order being made and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
	Signature ............................................................ ............
Declared before me, by ............................................................ ............................................................ ......
(name of Declarant)
who is personally known to me (or who is identified to me by ............................................................ .................
............................................................ ............................................................ ............................................................ ...
who is personally known to me), at ............................................................ .........................................
............................................................ ............................................................ ..............................................
on this ................................... day of ............................................................ ........................... 19..........
	Signature ............................................................ ............
	Description (k) ............................................................ ...
(a), (c), (d), (e), (f), (g), (h), (i) and (j) Delete words which do not apply. All deletions must be initialled by the declarant and by the person before whom the declaration is made.
(b) Where the identity of the applicant is not known to the consenting party the applicant should request the Board to assign a serial number to the application and this number should be inserted here.
(k) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or a person authorised by law to take and receive statutory declarations.

Form 6.

INTERIM ORDER.

WHEREAS an application has been made to An Bord Uchtala (hereinafter called "the Board") by ..............

by occupation .............................................. and resident at ............................................................ .........................

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

and his wife* ............................................................ hereinafter called "the applicant/applicants"* for an adoption order under the Adoption Acts, 1952 to 1988 (hereinafter called "the Acts") authorising him/her/them* to adopt

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

*born on the ............................................................ ......... * the probable date of whose birth has been determined by the Board to be the ............................................................ ............................................................ ......

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

*born on the ............................................................ ............................................................ . * the probable date of

whose birth has been determined by the Board to be the ............................................................ .........................

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

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled or is of opinion that such requirements are likely to be fulfilled before the expiration of the probationary period mentioned hereunder:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with .................................................... to whom the entry numbered ................................................ made on the ...................... day of ...................... 19............., in the Register of Births for the District of ............................................................ ............................ in the County of .......................................... relates:

NOW, THEREFORE, the Board orders as follows—

1. This application shall stand adjourned until further order;

2. The applicant/applicants* shall have custody of the child for a probationary period beginning on the ........................................................ and ending on the ................................................ *subject to the following conditions:

GIVEN under the Official Seal of the Board this .................... day of

................ 19 ............ Chairman/Registrar/a person authorised by

the Board to attest the seal of the Board*.

*Delete words which do not apply.

Form 7A.

ADOPTION ORDER.

WHEREAS an application has been made to An Bord Uchtala (hereinafter called "the Board") by ............................. by occupation ....................................... and resident at ........................................................ ............................................................ ............................................................ ............................................................ ..... and his wife ............................................................ hereinafter called "the applicants") for an adoption order under the Adoption Acts, 1952 to 1988 (hereinafter called "the Acts"), authorising them to adopt ............................................................ .....

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

born on the ............................................................ ............................................................ .......................................

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of each of the applicants to adopt the child and to the eligibility of the child to be adopted by the applicants have been fulfilled:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with ................................. to whom the entry numbered .................................. made on the ............... day of ................................ 19.........., in the Register of Births for the District of ............................................................ ........................................................ in the County of ............................................................ relates:

NOW, THEREFORE, the Board hereby makes an order for the adoption of the child by the applicants.

GIVEN under the Official Seal of the Board this .................... day of

.............. 19 ............ Chairman/Registrar/a person authorised by the

Board to attest the seal of the Board*.

*Delete words which do not apply.

Form 7B.

ADOPTION ORDER.

WHEREAS an application has been made to An Bord Uchtala (hereinafter called "the Board") by ................................ by occupation .................................... and resident at ............................................................ ..... ............................................................ ............................................................ ............................................................ ........ and his wife* ............................................................ hereinafter called "the applicant/applicants"*)for an adoption order under the Adoption Acts, 1952 to 1988 (hereinafter called "the Acts") authorising him/her/them* to adopt ............................................................ ............................................................ ................................................* born on the ............................................................ .../* the probable date of whose birth has been determined by the Board to be the ............................................................ ............................................................ ............................................................ .......

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with .......................................... to whom the entry numbered ................................. made on the ................... day of ................... 19........., in the Register of Births for the District of ............................................................ ............................................................ .................... in the County of relates:

NOW, THEREFORE, the Board hereby makes an order for the adoption of the child by the applicant/applicants*.

GIVEN under the Official Seal of the Board this .................... day of ................

19 ............ Chairman/Registrar/a person authorised by the Board to attest

the seal of the Board*.

*Delete words which do not apply.

Form 7C.

ADOPTION ORDER.

WHEREAS an application has been made to An Bord Uchtala (hereinafter called "the Board") by ..............................by occupation .............................. and resident at ............................................................ ........

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

and his wife ............................................................ .. (hereinafter called "the applicants") for an Adoption Order under the Adoption Acts, 1952 to 1988 (hereinafter called "the Acts"), authorising them to adopt

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

born on the ............................................................ ............................................................ ...........................................

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of each of the applicants to adopt the child have been fulfilled:

AND WHEREAS the Board is satisfied that in the particular circumstances of this case it is desirable to make an adoption order notwithstanding that the child was more than seven years of age at the date of the application for this order:

AND WHEREAS the Board is satisfied that the child is otherwise eligible to be adopted by the applicants:

AND WHEREAS the Bord has given due consideration to the wishes of the child having regard to his/her* age and understanding:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with ......................................to whom the entry numbered ................................. made on the ................ day of ............................................... 19.............., in the Register of Births for the District of ............................................................ ...................................... in the County of ............................................................ ............................................................ ......................... relates.

NOW, THEREFORE, the Board hereby makes an order for the adoption of the child by the applicants.

GIVEN under the Official Seal of the Board this .................... day of ................

19 ............ Chairman/Registrar/a person authorised by the Board

to attest the seal of the Board*.

*Delete words which do not apply.

Form 7D.

ADOPTION ORDER.

WHEREAS an application has been made to An Bord Uchtala (hereinafter called "the Board") by................

by occupation ................................................ and resident at ............................................................ ..

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

and his wife* ............................................................ (hereinafter called "the applicant/applicants"*) for an adoption order under the Adoption Acts, 1952 to 1988 (hereinafter called "the Acts") authorising him/her/them to adopt ............................................................ ............................................................ ............. born on the .................................................../* the probable date of whose birth has been determined by the Board to be the ............................................................ ............................................................ ....................

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child have been fulfilled:

AND WHEREAS the Board is satisfied that the child is otherwise eligible to be adopted by the applicant/applicants*:

AND WHEREAS the Board has given due consideration to the wishes of the child having regard to his/her* age and understanding:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with ................................................. to whom the entry numbered ............................... made on the .............. day of .......................... 19............, in the Register of Births for the District of .........................................in the County of ............................................................ ................................ relates.

NOW, THEREFORE, the Board hereby makes an order for the adoption of the child by the applicant/applicants*.

GIVEN under the Official Seal of the Board this .................... day of

................ 19 ............ Chairman/Registrar/a person authorised by the

Board to attest the seal of the Board*.

*Delete words which do not apply.

Form 8.

APPLICATIONS FOR REGISTRATION OF ADOPTION SOCIETY.

I, the undersigned person, being duly authorised on behalf of the adoption society called ............................................. hereby apply to an Bord Uchtala (hereinafter called "the Board") to have the society registered under the Adoption Acts, 1952 to 1988 as an adoption society. The following are particulars of the Society.

1. Address of society's headquarters		............................................................ .......................
		(block letters)
		............................................................ .........................
2. Date of establishment		............................................................ ..........................
3. Objects of the society (A copy of the society's constitution or other instrument (if any) governing its activities should be attached).		............................................................ .........................
4. Full names, addresses, occupations, experience in social work and related qualifications (if any) of:
(a) all members of the committee controlling the activities of the society and		Attach separate lists.
(b) all persons employed by the society, whether voluntary or paid, on work connected with adoption.
5. Full names, addresses, and qualifications of:
(a) the society's medical adviser		............................................................ ..........................
		............................................................ ..........................
		............................................................ ..........................
(b) the society's legal adviser		............................................................ ..........................
		............................................................ ..........................
		............................................................ ..........................
6. How is the society financed?		............................................................ ..........................
		............................................................ ..........................
		............................................................ ..........................
7. State briefly how the society proposes to function as a registered adoption society — in what children it proposes to interest itself and in what circumstances it proposes to arrange adoptions.		............................................................ ..........................
		............................................................ ..........................
		............................................................ ..........................
............................................................ ..........................
8. Does the society propose to confine its activities to work connected with adoption? (if not, give particulars of other services to be provided)		............................................................ .......................
		............................................................ .........................
............................................................ .........................
9. What arrangements will the society make for the care of children awaiting placement for adoption?		............................................................ ........................ ............................................................ ......................... ............................................................ ........................
The society hereby undertakes:—
(a) To furnish to the Board such further information as the Board may think necessary to enable it to determine if the society is entitled to be registered, and
(b) If registered, to make available to the Board, when requested, in relation to any and every child with whose proposed adoption the society is concerned, all material facts known to the society relating to the child, to the child's natural parents and to the proposed adopters, for the assistance and guidance of the Board prior to the making of an adoption order.
STATUTORY DECLARATION.
I ............................................................ ............................................................ ............................................................ ....
do solemnly and sincerely declare that the foregoing particulars stated in this application are true and I made this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .
Signature		............................................................ ..........................
Office held in the Society		............................................................ ..........................
Address		............................................................ .......................... ............................................................ ..........................
Date		............................................................ ..........................
Declared before me, by ............................................................ ..................................................... (name of declarant)
who is personally known to me (or who is identified to me, by
............................................................ ............................................................ ............................................................ .............
who is personally known to me) at ............................................................ ..........................................................
on this ...................................... day of ............................................................ ........................................ 19...............
		Signed............................................................ ..........
		Description (h) ......................................................
(a) This declaration should be made before a Notary Public or a Commissioner for Oaths or a Peace Commissioner.

Form 9.

FORM OF ENTRY IN ADOPTION SOCIETIES REGISTER.

Serial No.	Name of Society	Address of Society's Headquarters	Name and address of Chairman/ President of Society	Name and address of Secretary of Society	Date of application for registration	Date of registration	Remarks

Form 10.

ADOPTION ACTS, 1952 TO 1988.

Memorandum to be furnished by a registered adoption society to a mother, father or guardian who proposes to place a child with a registered adoption society for adoption.

Name of Registered Adoption Society	............................................................ ....................................................
Address	............................................................ ....................................................
	............................................................ ....................................................
Telephone No.	............................................................ ....................................................
Consent to the placing for adoption of ............................................................ ............................................. (here set out name of child) born on the ........................... day of ............................................................ .... 19.............................

Effect of an Adoption Order

1. If an adoption order is made for the child, you will lose all your parental rights and will be freed from all parental duties. These rights and duties will be transferred permanently to the adopters. The child will thereafter be regarded as their child as if the child were born to them in marriage.

Payments by Natural Father

2. If the child was born outside marriage and the natural father is under a legal obligation to make payments for the benefit of the child, he will not be legally bound to continue these payments after the adoption order is made.

Consent to the Making of an Adoption Order

3. An Bord Uchtala (The Adoption Board) will not make an adoption order without the consent of

(a) the mother of the child,

(b) any person appointed by court order or otherwise to be the child's guardian,

unless any such consent is dispensed with by the Board in accordance with the law.

4. The consent of the natural father to the making of an adoption order for a child born outside marriage is required in the following circumstances—

(a) where he marries the mother after the birth of the child, or

(b) where he has been appointed a guardian of the child or has been granted custody of the child pursuant to a court order (or otherwise has custody).

5. Where the prospective adopters, the child and the natural parents, or if the child was born outside marriage, his mother, are not all of the same religion, every person whose consent to the making of an adoption order is required must know, when giving such consent, the religion (if any) of each of the prospective adopters.

6. A consent may be withdrawn at any time before the making of an adoption order,

Dispensing with Consent

7. The law permits An Bord Uchtala (The Adoption Board) to dispense with the consent of any person to the making of an adoption order if it is satisfied that that person (a) is incapable by reason of mental infirmity of giving consent, or (b) cannot be found.

8. Where a person who has consented to the placing of a child for adoption fails, neglects or refuses to give consent to the making of an adoption order, or withdraws a consent already given, it is open to the prospective adopters, if they have applied for an adoption order for the child, to apply to the High Court for an order under section 3 of the Adoption Act, 1974 . The High Court, if it is satisfied that it is in the best interests of the child so to do, may make an order under that section (a) giving custody of the child to the prospective adopters, and (b) authorising An Bord Uchtala (The Adoption Board) to dispense with such consent to the making of an adoption order in their favour.

Reclaim of Child

9. If, after the child has been placed with prospective adopters and before the making of the adoption order, you change your mind and want to reclaim your child, you should contact the adoption society without delay. If the prospective adopters decline to give up the child, it is open to you to institute proceedings to have custody of the child restored to you. Should this situation arise you would need to consult a solicitor as a court case may be involved.

RECEIPT FOR FORM 10.

(Detach here).

To the registered adoption society called ............................................................ ...............................................
............................................................ ............................................................ ............................................................ ..
I hereby consent to the placing for adoption of the child ............................................................ ........................
............................................................ ............................................................ ............................................................ ..
(here set out the name of the child) born on the ...................................... day of .............................. 19.............
I say that I am/I am not the sole guardian of the said child. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (a)
To the best of my knowledge and belief, the father has not instituted proceedings in relation to guardianship or custody of the said child. (b)
Here you may state your wishes as to the religion, if any, of the persons(s) with whom the said child is to be placed for adoption............................................................ ............................................................ ................................................
I have received from you a statement in Form 10. That statement was attached to this receipt and I have myself torn it off. I understand that statement. I also understand that my signature on this receipt is evidence that I have consented to the placing of the said child for adoption.
Name (in block letters) ............................................................ ............................................................ .................
Signature ............................................................ ............................................................ ......................................
Address ............................................................ ............................................................ .......................................
Signature of Witness ............................................................ ............................................................ .....................
Address ............................................................ ............................................................ .........................................
............................................................ ............................................................ ..........................................
Occupation or Description ............................................................ ............................................................ ..........
Date ............................................................ ............................................................ ...............................................
I certify that on behalf of ............................................................ ............................................................ .....................
I have handed the statement attached to this receipt to ............................................................ ............................
............................................................ ........................................................... and explained its contents to her/him.
I am satisfied that she/he understands it.
	Signature ............................................................ .........................
	Date............................................................ .................................

(a) and (b) Delete words which do not apply.

Form 11.

NOTICE OF REGISTRATION OF ADOPTION SOCIETY.

(To be published by the Board in Irish Oifigiuil).

An Bord Uchtala has registered ............................................................ ........................................ in the Adoption Societies Register.

Form 12.

NOTICE OF CANCELLATION OF REGISTRATION OF ADOPTION SOCIETY.

(To be published by the Board in Iris Oifigiuil).

An Bord Uchtala has cancelled the registration of ............................................................ .................................... in the Adoption Societies Register.

Form 13.

AN BORD UCHTALA.

In the matter of an application for an adoption order by/for

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

To: ............................................................ ............................................................ ............................................................ ..

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

In exercise of the powers conferred on it by Clause 9 of the First Schedule to the Adoption Act, 1952 , An Bord Uchtala (The Adoption Board) hereby summons you to attend before it .................................................

at ............................................................ ............................................................ ........................ on the..........................

day of ............................................................ .................................. 19........... at ......................................... to give evidence in relation to the above-mentioned matter.

GIVEN under the Official Seal of the Board this .................... day of ................ 19 ............ Chairman/Registrar/a person authorised by the Board to attest the seal of the Board*.

*Delete words which do not apply.

Note: If you do not obey this Summons you are liable on summary conviction to a fine not exceeding Twenty-Five Pounds.

EXPLANATORY NOTE.

These rules prescribe forms to be used for the purposes of the Adoption Acts, 1952 to 1988. They replace similar rules made in 1976 and 1984.

The Adoption Rules 1988 ( S.I. No. 304 of 1988 ) which prescribe forms to be used for the purposes of the Adoption Act, 1988 are not affected.