CONSENT BY INSTITUTION
The ______________________________________________ ( Institution), as represented by __________________________________, its duly authorized representative, by virtue of the authority vested in it by _________________________________ (State), in regard to ___________________________________(Name), a ___________ (Male/Female) child who was born ____________(Date), and who was lawfully relinquished to the above-referenced institution on ___________(Date), for the purpose of placing the above-named child with a suitable family for adoption, does hereby consent to _______ (His/Her) adoption by _________________________ and ______________________________, husband and wife.
In witness whereof, I have signed this instrument in my capacity as the duly authorized representative of ____________________________________ (Institution) on ____________, _____.
Signature and Title
This document was signed in the presence of the following: