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

Type Statutory Instrument
Publication 1990-07-06
Last updated 2010-07-14
State Repealed superseded text
Text As published
Source Irish Statute Book
articles 13

This is the act as published. Later amendments are not folded into the text below: each one is a separate act in this repository and an entry in this law's history.

2 amending acts · 2010-07-14, Adoption Act 2010

Reform history JSON API
In the matter of an application for the adoption of the child............................................................ ................... In the matter of an application for the adoption of the child............................................................ ...................
............................................................ ............................................................ ............................................................ ..... ............................................................ ............................................................ ............................................................ .....
I, ............................................................ ........................................ (name) of ............................................................ .. I, ............................................................ ........................................ (name) of ............................................................ ..
............................................................ ............................................................ ............................................... (address) ............................................................ ............................................................ ............................................... (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:— 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....................................... 1. I am aware that an application is about to be made or has been made by.......................................
............................................................ ............................................................ ........................................... ............................................................ ............................................................ ...........................................
of............................................................ ............................................................ ...................................... ............................................................ ............................................................ .......................................... of............................................................ ............................................................ ...................................... ............................................................ ............................................................ ..........................................
for an adoption order in respect of the said child. 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) 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) 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............................................................ ............. 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............................................................ ................. 5. I know that the religion of the male applicant is............................................................ .................
and that the religion of the female 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. 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. 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. 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. 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. 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:— 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) (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) (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 . 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 ............................................................ ........................ 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............................................................ ................................ who is personally known to me), at............................................................ ................................
............................................................ ............................................................ ......................................... ............................................................ ............................................................ .........................................
on this ...............................day of .......................................... 19............ 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. (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. (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............................................................ ................ In the matter of an application for the adoption of the child............................................................ ................
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
I, ............................................................ ................................ (name) of ............................................................ ...... I, ............................................................ ................................ (name) of ............................................................ ......
............................................................ ............................................................ ..............................................(address) ............................................................ ............................................................ ..............................................(address)
Spinster/Married/Divorced/Widow (a) aged eighteen years and upwards (or, if under eighteen, aged .......................... years), make oath and say as follows:— 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. 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. 2. I am the mother of the said child.
3. I did/did not marry the father of the child. (c) 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) 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) 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................. 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 ............................................................ .................. 7. I know that the religion of the male applicant is ............................................................ ..................
and that the religion of the female 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. 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. 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. 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. 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. 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:— 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) (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) (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. 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............................................................ .......... 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). 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. (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. (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. (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 ............................................................ .................... In the matter of an application for the adoption of the child ............................................................ ....................
............................................................ ............................................................ ............................................................ ..... ............................................................ ............................................................ ............................................................ .....
I, ............................................................ ....................................... (name) of ............................................................ ... 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:— ............................................................ ............................................................ .................................................. (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. 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) 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) 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............. 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 ............................................................ ..................... 5. I know that the religion of the male applicant is ............................................................ .....................
and that the religion of the female 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. 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. 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. 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. 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. 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:— 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) (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) (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. 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 ............................................................ . Sworn at ........................................................... in the county of ............................................................ .
on this ........................ day of ............................................................ ................................... 19.................. on this ........................ day of ............................................................ ................................... 19..................
before me, and I know the deponent (or and I know ............................................................ .............. before me, and I know the deponent (or and I know ............................................................ ..............
............................................................ ............................................................ ........................................... ............................................................ ............................................................ ...........................................
who certifies to me that he knows the deponent). 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. (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. (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. (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 ............................................................ .......................... In the matter of an application for the adoption of the child ............................................................ .......................... In the matter of an application for the adoption of the child ............................................................ ..........................
............................................................ ............................................................ ............................................................ ........... ............................................................ ............................................................ ............................................................ ........... ............................................................ ............................................................ ............................................................ ...........
I, ............................................................ .................................................. (name) of .......................................................... I, ............................................................ .................................................. (name) of .......................................................... 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:— ............................................................ ............................................................ .................................................... (address) Spinster/Married/Divorced/Widow (a) aged eighteen years and upwards (or, if under eighteen, aged .................... years), do solemnly and sincerely declare that:— ............................................................ ............................................................ .................................................... (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. 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. 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. 2. I am the mother 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) 3. I did/did not marry the father of the said child. (c) 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) 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) 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) 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) 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................. 6. The said child is not less than six weeks old, having been born on the ............. day of .......... 19................. 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 ............................................................ ........................... 7. I know that the religion of the male applicant is ............................................................ ........................... 7. I know that the religion of the male applicant is ............................................................ ...........................
and that the religion of the female applicant is ............................................................ .......................... and that the religion of the female 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. 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. 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. 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. 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. 10. I hereby freely give my consent to the making of an adoption order in pursuance of the application referred to above. 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. 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. 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. 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. 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:— 13. I say that my wishes in respect of the matters referred to in paragraph 12 above are as follows:— 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) (i) I do/I do not wish to be heard on the application for the adoption order. (f) (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) (ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (g) (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 . 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 . 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 ............................................................ ............... Signature ............................................................ ...............
Declared before me, by ............................................................ ........................................ (name of declarant) who is personally known to me (or who is identified to me by........................................ Declared before me, by ............................................................ ........................................ (name of declarant) who is personally known to me (or who is identified to me by........................................ 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 ............................................................ .............................................. who is personally known to me), at ............................................................ .............................................. who is personally known to me), at ............................................................ ..............................................
on this ......................................................... day of ............................................................ ..... 19................. on this ......................................................... day of ............................................................ ..... 19................. 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. (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. (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. (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. (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. (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. (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 ............................................................ .................... In the matter of an application for the adoption of the child ............................................................ ....................
............................................................ ............................................................ ............................................................ ..... ............................................................ ............................................................ ............................................................ .....
I, ............................................................ ............................................... (name) of........................................................ I, ............................................................ ............................................... (name) of........................................................
............................................................ ............................................................ ................................................ (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen years ............................................................ ............................................................ ................................................ (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:— 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. 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) 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) 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............. 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 ............................................................ ....................... 5. I know that the religion of the male applicant is ............................................................ .......................
and that the religion of the female 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. 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. 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. 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. 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. 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:— 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) (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) (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 . 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............................................................ ............................................ 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 ............................................................ .......................................... who is personally known to me), at ............................................................ ..........................................
............................................................ ............................................................ ........................................... ............................................................ ............................................................ ...........................................
on this ................................................... day of ............................................... 19................................. 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. (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. (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. (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 ............................................................ ............... In the matter of an application for the adoption of the child ............................................................ ...............
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
I, ............................................................ ................................................. (name) of................................................... I, ............................................................ ................................................. (name) of...................................................
............................................................ ............................................................ ................................................. (address) Bachelor/Spinster/Married/Divorced/Widow/Widower (a) aged eighteen ............................................................ ............................................................ ................................................. (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:— 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 ....................................... 1. I am aware that an application is about to be made or has been made by .......................................
of ............................................................ ............................................................ ......................................... of ............................................................ ............................................................ .........................................
for an adoption order in respect of the said child. 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) 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) 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) 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) 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) 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.......... 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 ............................................................ ............................ 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. 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. 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) 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. 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. 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:— 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) (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) (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. 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 .......................................................... Sworn at ............................................................ . in the county of ..........................................................
on this .................. day of ............................................................ .................................................. 19...... on this .................. day of ............................................................ .................................................. 19......
before me, and I know the deponent (or and I know............................................................ ............ before me, and I know the deponent (or and I know............................................................ ............
............................................................ ............................................................ ........................................... who certifies to me that he knows the deponent). ............................................................ ............................................................ ........................................... 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. (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. (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)

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