parents to be present when this affidavit is executed and to sign it as a witness. The witness I selected is: {full legal name} . 3. [ only one] ( ) I consent to my name being legally changed to {specify new name that you wish . to have upon completion of the adoption process} ( ) I do not consent to a name change. I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this consent and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Adoptee Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: Home Address: Signature of Witness Printed Name: or Business Address: Driver’s License State ID Card No.: Home Address: or ______________________________ Driver’s License Signature of Witness State ID Card No.: Printed Name: Business Address: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on by . NOTARY PUBLIC or DEPUTY CLERK [Print, type, or stamp commissioned name of notary or clerk.] Personally known Produced identification Type of identification produced IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ fill in all blanks] I, , {full legal name and trade name of nonlawyer} a nonlawyer, located at , , {street} {city} , , helped , {state} {phone} {name} who is the adoptee, fill out this form.
parents to be present when this affidavit is executed and to sign it as a witness. The witness I selected is: {full legal name} . 3. [ only one] ( ) I consent to my name being legally changed to {specify new name that you wish to have upon completion of the adoption process} . ( ) I do not consent to a name change. I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this consent and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Adoptee Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: Signature of Witness Printed Name: Business Address: Home Address: ______________________________ Signature of Witness Printed Name: Business Address: Home Address: Driver’s License or State ID Card No.: Driver’s License or State ID Card No.: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on by . NOTARY PUBLIC or DEPUTY CLERK [Print, type, or stamp commissioned name of notary or clerk.] Personally known Produced identification Type of identification produced IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ fill in all blanks] I, {full legal name and trade name of nonlawyer} , a nonlawyer, located at {street} , {city} , {state} , {phone} , helped {name} , who is the adoptee, fill out this form.
Adult-Adoption-Packet.docx