COMMONWEALTH OF VIRGINIA CONSENT TO ADOPTION

In the      Court of      

In the Matter of the Proposed Adoption of      
Birth Registration Number:      

The Board of Social Services of      represents to the Court that it is a child-placing agency as defined in Section
63.2-100 of the Code of Virginia, as amended, and is authorized to receive and place children pursuant to
authority granted it under the provisions of Section 63.2-900 of the Code.

That the said Board has the authority to place and consent to this child’s adoption because:

parental rights were terminated by court action and the order of commitment provided the       Board of
Social Services with the authority to place and consent to the child’s adoption.

mother, date      

putative father, date      
unknown father, date      
legal father, date      

the child was entrusted to its care and custody on      by      mother of said child      and/or on      by      
father of said child. That the Entrustment Agreement was for the purpose of adoption placement and authorized
the said Board of Social Services to place and consent to the child’s adoption. The Entrustment Agreement
provided for the termination of parental rights and has not been revoked.

the identity of the father of said child is unknown, as attested to be affidavit of the mother

the putative father signed an affidavit either denying paternity, acknowledging paternity or
neither denying nor acknowledging paternity and waived all rights to further notice.

the putative father received notice of the mother’s entrustment by certified letter and failed to object to
the mother’s entrustment within 15 days of receipt of the letter.

Now, therefore, the      Board of Social Services certifies to the Court that on      it caused the child to be placed
in the home of      and      who are petitioning the Court for the adoption of this child, and herewith consents to
the proposed adoption.

In Witness Whereof, the said Board of Social Services has caused this instrument to be signed
by its Chairman and Director/Superintendent of Social Services this      day of      
, 20     
.

032-02-0655-02-eng (02/08)
      Board of Social Services

By: ______________________________________
Chairman

__________________________________________
Director/Superintendent

This form is signed under oath and acknowledged before an officer authorized by law to take acknowledgement.

STATE OF VIRGINIA

COUNTY/CITY OF _________________________________________________ to-wit:

I, ________________________________________, a Notary Public in and for the County/City aforesaid,

in the State of Virginia, do hereby certify that _______________________________________ and

______________________________________________________ whose names are signed to the foregoing

Consent to Adoption have each acknowledged the same before me in my County/City aforesaid.

My commission expires ________________________________________________________

Give under my hand this _________________ day of ______________________, 20______.

__________________________________________________________
Notary Public

032-02-0655-02-eng (02/08)