S.I. No. 519/2010 - Adoption Act 2010 (Consent to Adoption Order) (Forms) Regulations 2010.

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S.I. No. 519/2010 - Adoption Act 2010 (Consent to Adoption Order) (Forms) Regulations 2010.

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Notice of the making of this Statutory Instrument was published in
“Iris Oifigiúil” of 5th November, 2010.
I, BARRY ANDREWS, Minister of State at the Department of Health and Children, in exercise of the powers conferred on me by section 150 of the Adoption Act 2010 (No. 21 of 2010) and the Health and Children (Delegation of Ministerial Functions) Order 2010 ( S.I. No. 508 of 2010 ), hereby make the following regulations:
1. These regulations may be cited as the Adoption Act 2010 (Consent to Adoption Order) (Forms) Regulations 2010.
2. These regulations come into operation on 2 November 2010.
3. Each of the forms set out in the Schedule shall be used in the case and manner indicated in the form.
SCHEDULE forms of consent to adoption
Form 1
The Adoption Authority of Ireland
AFFIDAVIT OF CONSENT TO ADOPTION
(For use by a mother where the identity of the applicant(s) is known to her)
In the matter of an application for the adoption of .
(child’s full name)
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
.............................. (names(s))
of ............................. (address)
for an adoption order in respect of the said child.
2. I am the mother of the said child.
3. I did / I did not marry the father of the said child. (*b)
4. I am / I am not the sole guardian of the said child. (*c)
5. The father has/has not been appointed a guardian of the said child pursuant to a court order or otherwise. (*d)
6. To the best of my knowledge and belief the father has / has not instituted proceedings in relation to access to, or guardianship or custody of, the said child. (*e)
7. The said child is not less than six weeks old, having been born on the ............ day of ......... 20....
8. I know that the religion of the male applicant is ............................. and that the religion of the female 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 or adopters.
10. I have been informed and I understand that the Adoption Authority of Ireland 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.
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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
14. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
15. 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; (*f)
(ii) I do/I do not wish otherwise to be consulted again in relation to the application for the adoption order. (*g)
16. 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 ......................... 20....... .
before me and I know the deponent (or I know ......................................................,
who certifies to me that (s) he knows the deponent).
Signature .......................................................................
Description (*h) .............................
(*a), (*b), (*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.
(*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 2
The Adoption Authority of Ireland
AFFIDAVIT OF CONSENT TO ADOPTION
(For use by a person other than the mother where the identity of the applicant(s) is known to the consenting party)
In the matter of an application for the adoption of .
(child’s full name)
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
............................. (names(s))
of ............................. (address)
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 .............., 20 .........
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 the Adoption Authority of Ireland 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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
11. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
12. 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)
13. 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.........................20.........
before me and I know the deponent (or I know......................................................,
who certifies to me that (s) he knows the deponent).
Signature......................................................................................
Description (*f)........................................................................................
(*a), (*b), (*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.
(*c) Delete entire line if it does not apply. The deletion 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.
The Adoption Authority of Ireland
Form 3
DECLARATION OF CONSENT TO ADOPTION
(For use by a mother where the identity of the applicant(s) is known to her)
In the matter of an application for the adoption of .
(child’s full name)
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
.............................. (names(s))
of ............................., (address)
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. (*c)
5. The father has / has not been appointed a guardian of the said child pursuant to a court order or otherwise. (*d)
6. To the best of my knowledge and belief the father has / has not instituted proceedings in relation to access to, guardianship or custody of, the said child. (*e)
7. The said child is not less than six weeks old, having been born on the ..................................... day of ................................... 20 ......
8. I know that the religion of the male applicant is ............................. and that the religion of the female 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 or adopters.
10. I have been informed and I understand that the Adoption Authority of Ireland 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.
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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
14. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
15. 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; (*f)
(ii) I do / I do not wish otherwise to be consulted again in relation to the application for the adoption order. (*g)
15. I understand that this declaration may be used as evidence that I consent to the adoption order being made.
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...........................................20..
Signature........................................................................
Description (*h) .............................
(*a), (*b), (*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.
(*h) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or other person authorised by law to take and receive statutory declarations.
Form 4
The Adoption Authority of Ireland
DECLARATION OF CONSENT TO ADOPTION
(For use by a person other than the mother where the identity of the applicant(s) is known to the consenting party)
In the matter of an application for the adoption of .
(child’s full name)
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
............................. (names(s))
of.............................. (address)
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...................................., 20.....
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 the Adoption Authority of Ireland 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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
11. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
12. 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)
13. I understand that this declaration may be used as evidence that I consent to the adoption order being made.
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...........................................20..
Signature.................................................................
Description (*f)..............................................................................................
(*a), (*b), (*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.
(*c) Delete entire line if it does not apply. The deletion 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 other person authorised by law to take and receive statutory declarations.
Form 5
The Adoption Authority of Ireland
AFFIDAVIT OF CONSENT TO ADOPTION
(For use by a mother where the identity of the applicant(s) is not known to her)
In the matter of an application for the adoption of .
(child’s full name)
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 / I did not marry the father of the said child. (*c)
4. I am / I am not the sole guardian of the said child. (*d)
5. The father has / has not been appointed a guardian of the said child pursuant to a court order or otherwise. (*e)
6. To the best of my knowledge and belief the father has / has not instituted proceedings in relation to access to, or guardianship or custody of, the said child. (*f)
7. The said child is not less than six weeks old, having been born on the day of .20 .
8. I know that the religion of the male applicant is............................. and that the religion of the female 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 or adopters.
10. I have been informed and I understand that the Adoption Authority of Ireland 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.
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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
14. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
15. 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; (*g)
(ii) I do / I do not wish otherwise to be consulted again in relation to the application for the adoption order. (*h)
16. 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.........................20.........
before me and I know the deponent (or I know...................................................... who certifies to me that (s) he knows the deponent).
Signature......................................................................................
Description (*i)..............................................................
(*a), (*c), (*d), (*e), (*f), (*g) and (*h): 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 Authority to assign a serial number to the application, and this number should be inserted here.
(*i) 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 6
The Adoption Authority of Ireland
AFFIDAVIT OF CONSENT TO ADOPTION
(For use by a person other than the 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 .
(child’s full name)
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 ..20.
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 the Adoption Authority of Ireland 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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
11. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
12. 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)
13. 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.........................20.........
before me and I know the deponent (or I know......................................................,
who certifies to me that (s) he knows the deponent).
Signature......................................................................................
Description (*g)..............................................................
(*a), (*c), (*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 Authority to assign a serial number to the application, and this number should be inserted here.
(*d) Delete entire line if it does not apply. The deletion 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 7
The Adoption Authority of Ireland
DECLARATION OF CONSENT TO ADOPTION
(For use by a mother where the identity of the applicant(s) is not known to her)
In the matter of an application for the adoption of .
(child’s full name)
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 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 / I did not marry the father of the said child. (*c)
4. I am / I am not the sole guardian of the said child. (*d)
5. The father has / has not been appointed a guardian of the said child pursuant to a court order or otherwise. (*e)
6. To the best of my knowledge and belief the father has / has not instituted proceedings in relation to access to, or guardianship or custody of, the said child. (*f)
7. The said child is not less than six weeks old, having been born on the .. day of ..20 .
8. I know that the religion of the male applicant is .............................and that the religion of the female 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 or adopters.
10. I have been informed and I understand that the Adoption Authority of Ireland 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.
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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
14. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
15. 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; (*g)
(ii) I do / I do not wish otherwise to be consulted again in relation to the application for the adoption order. (*h)
16. I understand that this declaration may be used as evidence that I consent to the adoption order being made.
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...........................................20.
Signature..........................................................................................................................
Description (*i)..............................................................
(*a), (*c), (*d), (*e), (*f), (*g) and (*h) 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 Authority to assign a serial number to the application, and this number should be inserted here.
(*i) This declaration may be made before a Notary Public, a Commissioner for Oaths, a Peace Commissioner or other person authorised by law to take and receive statutory declarations.
Form 8
The Adoption Authority of Ireland
DECLARATION OF CONSENT TO ADOPTION
(For use by a person other than the 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 .
(child’s full name)
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 ..20...
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 the Adoption Authority of Ireland 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 my so informing the Adoption Authority of Ireland, Shelbourne House, Shelbourne Road, Dublin 4, 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 in writing to the Authority my wishes in this respect. I also understand that if I wish to be heard I will be informed of the date on which the Authority will hear me or my counsel or solicitor.
11. I have been informed and I understand that, despite any subsequent withdrawal of my consent, the High Court, on application, may, at its discretion, authorise the Adoption Authority to dispense with my consent.
12. 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)
13. I understand that this declaration may be used as evidence that I consent to the adoption order being made.
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 ...........................................20 ..
Signature.........................................................................
Description (*g) ..............................................................
(*a), (*c), (*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 Authority to assign a serial number to the application and this number should be inserted here.
(*d) Delete entire line if it does not apply. The deletion 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 other person authorised by law to take and receive statutory declarations.
GIVEN under my hand,
2 November 2010.
BARRY ANDREWS,
Minister of State at the Department of Health and Children.
EXPLANATORY NOTE
(This Note is not part of the Instrument and does not purport to be a legal interpretation.)
These regulations set out the prescribed consent forms under section 26 of the Adoption Act 2010 (No. 21 of 2010).

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