DISCLAIMER
This template is provided for general informational purposes only and is not legal advice. Use of this form does not create an attorney-client relationship with the author or the platform. Mississippi adoption requirements change from time to time; a licensed Mississippi attorney must review, customize, and approve this document before use in any proceeding.

PARENTAL CONSENT TO ADOPTION

(State of Mississippi – Chancery Court)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title & Parties
This Parental Consent to Adoption (the “Consent”) is executed by:

• [BIOLOGICAL MOTHER NAME], an adult resident of [COUNTY], Mississippi (“Mother”);
• [BIOLOGICAL FATHER NAME] (if applicable), an adult resident of [COUNTY], Mississippi (“Father,” and together with Mother, the “Parent(s)”); and
• [PROSPECTIVE ADOPTIVE PARENT(S) NAME(S)], (“Petitioner(s)”).

1.2 Child
Name: [CHILD’S FULL LEGAL NAME]
Date of Birth: [MM/DD/YYYY]
Place of Birth: [CITY/COUNTY], Mississippi

1.3 Recitals
A. Parent(s) are the legal parent(s) of the Child.
B. Petitioner(s) have filed or intend to file a petition for adoption in the Chancery Court of [COUNTY] (the “Court”) pursuant to Miss. Code Ann. § 93-17-1 et seq.
C. Parent(s) desire to voluntarily, knowingly, and irrevocably (subject to Section 3.7 below)* relinquish all parental rights to the Child in favor of Petitioner(s) in accordance with Mississippi law.

1.4 Effective Date & Jurisdiction
This Consent is effective on the [DAY] day of [MONTH] [YEAR] (the “Effective Date”) and is governed exclusively by the laws of the State of Mississippi (“Governing Law”).

[// GUIDANCE: Insert court docket number once the adoption petition is filed.]

2. DEFINITIONS

“Adoption Proceeding” The action styled In the Matter of the Adoption of [Child’s Initials], docket no. [______], pending in the Court.

“Consent Timing Requirement” The statutory mandate that a birth mother may not execute a consent until at least seventy-two (72) hours have elapsed following the Child’s birth.†

“Counseling Requirement” The statutory or Court-ordered requirement that Parent(s) receive adoption-related counseling prior to executing this Consent.

“Revocation Period” The limited period, if any, during which Parent(s) may withdraw this Consent, currently permitted only by leave of the Court and prior to the entry of the final decree of adoption.†

“State” The State of Mississippi.

†[// GUIDANCE: Verify the precise timing and revocation provisions in effect on the execution date; insert statutory citations after attorney confirmation.]

3. OPERATIVE PROVISIONS

3.1 Voluntary Relinquishment
Parent(s) hereby voluntarily and permanently surrender all parental rights, custodial rights, and responsibilities with respect to the Child, including the right to custody, visitation, inheritance, decision-making, and any other legal incident of the parent-child relationship.

3.2 Consent to Adoption
Parent(s) unconditionally consent to the adoption of the Child by Petitioner(s) and request that the Court enter a final decree of adoption in favor of Petitioner(s) at the earliest lawful time.

3.3 Acknowledgment of Counseling
Parent(s) acknowledge that they:
(a) have been advised of their right to independent legal counsel;
(b) have either received the Counseling Requirement or have knowingly waived such counseling in writing; and
(c) understand the legal consequences of executing this Consent.

3.4 Timing Certification
Mother certifies that at least seventy-two (72) hours have elapsed since the Child’s birth (the “Consent Timing Requirement”), and that she is legally competent to execute this Consent.

3.5 Consideration
Parent(s) acknowledge receipt of good and valuable consideration, the adequacy and receipt of which are hereby confirmed. No consideration was offered or accepted that is inconsistent with Mississippi’s prohibitions on the payment or transfer of value for parental consent.

3.6 Conditions Precedent
The effectiveness of this Consent is conditioned upon:
(a) filing of the Adoption Proceeding with the Court within [___] days of the Effective Date; and
(b) issuance of an interlocutory or final decree of adoption in favor of Petitioner(s).

3.7 Revocation; Irrevocability
Subject to the Revocation Period and Mississippi Code provisions then in effect:
(a) Parent(s) may not unilaterally withdraw this Consent after its execution except upon written order of the Court entered prior to the final decree of adoption; and
(b) Upon entry of the final decree, this Consent becomes irrevocable for all purposes.

[// GUIDANCE: Practitioners sometimes incorporate a short “cooling-off” period (e.g., five (5) calendar days) even if not required by statute; modify as desired.]

4. REPRESENTATIONS & WARRANTIES

Parent(s) represent and warrant to Petitioner(s) and the Court that:

4.1 Legal Capacity Each Parent is at least eighteen (18) years of age, of sound mind, and under no legal disability.

4.2 Authority Each Parent has full legal authority to execute this Consent and is not subject to any court order, agreement, or proceeding that would restrict such authority.

4.3 No Duress or Fraud This Consent is executed freely, voluntarily, and without coercion, duress, fraud, or undue influence.

4.4 Full Disclosure Each Parent has disclosed to Petitioner(s) any known legal actions, claims, or circumstances that could affect the adoption.

4.5 Accuracy All information provided herein and in any supporting documents is true, complete, and accurate to the best of Parent(s)’ knowledge.

Survival
The representations and warranties in this Section survive execution of this Consent and entry of the final decree of adoption.

5. COVENANTS

5.1 Future Cooperation Parent(s) shall execute all additional documents and perform any acts reasonably necessary to consummate the adoption.

5.2 Non-Interference Parent(s) covenant not to contest, delay, or interfere with the Adoption Proceeding except as may be expressly permitted during the Revocation Period and by Mississippi law.

5.3 Notice of Address Change Parent(s) shall promptly notify the Court and Petitioner(s) of any change of address during the pendency of the Adoption Proceeding.

6. DEFAULT & REMEDIES

6.1 Events of Default
(a) Parent(s)’ filing of any pleading seeking to revoke this Consent outside the Revocation Period;
(b) Breach of Section 5.2 (Non-Interference).

6.2 Remedies
Upon any Event of Default, the Court may, in its discretion:
(a) dismiss such improper filing with prejudice;
(b) impose sanctions or attorney fees; and/or
(c) grant any equitable relief necessary to protect the Child’s best interests.

[// GUIDANCE: Family-law practitioners typically rely on the Court’s equitable powers rather than contract remedies; adjust as needed.]

7. RISK ALLOCATION

Indemnification and limitation of liability provisions are not applicable given the nature of this Consent. Parent(s) acknowledge that entering into this Consent entails the permanent surrender of parental rights and assume any attendant risks subject to oversight by the Court.

8. DISPUTE RESOLUTION

8.1 Governing Law This Consent is governed by, and construed in accordance with, the laws of the State of Mississippi, without regard to conflict-of-law principles.

8.2 Exclusive Forum The Chancery Court of [COUNTY], Mississippi, shall have sole and exclusive jurisdiction over any dispute arising out of or relating to this Consent.

8.3 Arbitration Arbitration is not available for disputes concerning adoption matters under Mississippi law.

8.4 Jury Trial Waiver Adoption matters are heard in chancery court without a jury; accordingly, no jury trial waiver is required.

8.5 Injunctive Relief Nothing in this Consent limits the Court’s broad equitable power to enter orders for the Child’s immediate protection and permanent placement.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver Any amendment of this Consent must be in writing, signed by all Parties, and approved by the Court. No waiver is effective unless in writing.

9.2 Assignment Parent(s)’ rights and obligations hereunder are personal and may not be assigned.

9.3 Severability If any provision is held invalid or unenforceable, the remainder shall be interpreted to carry out the Parties’ intent to the maximum lawful extent.

9.4 Integration This Consent is the entire agreement of the Parties with respect to the subject matter and supersedes all prior understandings.

9.5 Counterparts This Consent may be executed in counterparts, each of which is deemed an original, and all of which together constitute one instrument.

9.6 Electronic Signatures Signatures transmitted by electronic means shall be deemed original for all purposes, subject to Mississippi Uniform Electronic Transactions Act compliance.

10. EXECUTION BLOCK

Executed and acknowledged on the date first written above.

10.1 Biological Mother

[BIOLOGICAL MOTHER NAME]

State of Mississippi
County of [__]

On this ___ day of __, 20, before me, the undersigned Notary Public, personally appeared [BIOLOGICAL MOTHER NAME], known or satisfactorily proven to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that she executed the same for the purposes therein contained.

(seal)

Notary Public
My Commission Expires: ____

10.2 Biological Father (if applicable)

[BIOLOGICAL FATHER NAME]

State of Mississippi
County of [__]

[Duplicate notary block as above]

10.3 Prospective Adoptive Parent(s) Acknowledgment (optional)

I/We hereby accept the surrender of parental rights as set forth herein and agree to proceed with the adoption of the Child.

[PROSPECTIVE ADOPTIVE PARENT #1 NAME]

[PROSPECTIVE ADOPTIVE PARENT #2 NAME] (if any)

10.4 Attorney Certification (strongly recommended)

I certify that I have explained the legal significance of this Consent to my client(s) and am satisfied that it is executed knowingly and voluntarily.

[ATTORNEY NAME], MSB #_
Counsel for [Mother/Father]

[// GUIDANCE:
1. Attach any required statutory disclosure forms or exhibits (e.g., medical histories, counseling certificates).
2. Provide the executed original to the Court; retain certified copies for all Parties.
3. Verify local chancery court rules regarding witness requirements—certain judges require an additional adult witness or Guardian ad Litem endorsement.
4. Insert precise statutory citations after attorney verification to comply with the “100 % accuracy” rule.]

END OF DOCUMENT