[ ] The child is not disabled or is disabled but the disability would not affect the child's ability to understand the meaning of consenting to adoption.
OR
[ ] The child has a disability that could affect the child's ability to understand the meaning of consenting to adoption. The disability is __________. Despite the child's disability, I believe that the child understands the meaning of the consenting to adoption. The following additional steps were taken to ensure that the child understood the meaning of the consent form prior to signing it: __________.
I solemnly affirm under the penalties of perjury that the contents of this affidavit are true to the best of my knowledge, information, and belief.
_________________________________ | _________________________________ |
(Date) | (Signature) |
_________________________________ | |
(Printed Name) | |
_________________________________ | |
(Address) | |
_________________________________ | |
(City, State, Zip Code) | |
_________________________________ | |
(Telephone Number) |
Md. Fam. Law. Actions., Form 9-102.9