Birthmother Non-Identifying Information

  • Birth Parent Situation

  • We
  • have received and reviewed the information provided to us about birth parent(s)
  • with the expected due date of:
  • including the social history and non-identifying health and genetic background forms. We have spoken with Act of Love and had the opportunity to have our questions about this situation answered.
  • We understand that the fees and expenses for this adoption are expected to be $
  • We also understand that other possible expenses may include, but are not limited to:
  • We understand that finalization and court ordered termination of parental rights require additional fees to attorneys, which may exceed what is presented regarding the cost of this adoption and will be our responsibility.
    The birth mother has:
  • We understand that medical charges not covered by Medicaid or other insurance must be paid by us.
  • We understand it is anticipated that the birth parent(s) will be signing consents or relinquishments under the law
  • law
  • We also understand it is expected that the baby will be born in the State of
  • If the baby will NOT be born in Utah, we understand that we must discuss with our attorney whether the adoption can be finalized in our home state using Utah agency relinquishment documents. If not, we will discuss with Act of Love.
  • We understand the birth father is:
  • Explain
  • We understand it is believed that the father resides in the State of
  • We also understand that if he is not consenting, steps may need to be taken in his State to terminate his rights to this child. We realize this may take several weeks after the birth of the baby to resolve.
  • We understand the birth mother’s marital status is:
  • We understand the birth mother’s marital status is:
  • Please refer to the social history for the birth parent(s)’ desired openness/post adoption contact. NOTE: Openness/Post Adoption Contract requests frequently change prior to placement. We acknowledge that openness agreements are enforceable in some states. We will check with an attorney in our state and the state of the baby’s birth to see if openness agreements are enforceable in either state. We understand that this is for informational purposes only to facilitate a match. We also understand that Act of Love necessarily obtains its information from the birth parents, and circumstances could change that would make some of the information contained herein incorrect or that could cause an increase in anticipated expenses. We release and hold harmless Act of Love from any and all liability resulting from any information changing, from any information being incorrect, or from any changes in circumstances or facts. We understand that this information is confidential and we WILL NOT DISCLOSE any of this information to anyone including family members, co-workers, or other adoptive families. After reviewing this information and the non-identifying information:
  • Please DO NOT present our profile. REASON:
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • We understand that if ICPC is required, we may not return home until ICPC has been approved by all necessary States, which may take 5-10 business days after discharge. (Please initial)
  • A Act of Love 9561 South 700 East, Sandy, Utah 84070 Phone: (801) 572-1696 Fax: (801) 572-9303 1.20
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