Massachusetts General Laws
Chapter 210 - Adoption of Children and Change of Names
Section 2 - Written Consent of Certain Persons; Form of Consent; Identification of Father

Section 2. A decree of adoption shall not be made, except as provided in this chapter, without the written consent of the child to be adopted, if above the age of twelve; of the child's spouse, if any; of the lawful parents, who may be previous adoptive parents, or surviving parent; or of the mother only if the child was born out of wedlock and not previously adopted. A person whose consent is hereby required shall not be prevented from being the adoptive parent.
Such written consent shall be executed no sooner than the fourth calendar day after the date of birth of the child to be adopted. It shall be attested and subscribed before a notary public in the presence of two competent witnesses, one of whom shall be selected by said person. The agency or person receiving custody shall act as guardian of the child until such time as a court of competent jurisdiction appoints a guardian or grants a petition for adoption. Execution of such consent shall be carried out in a manner which shall preserve privacy and confidentiality. A copy of said consent shall be filed with the department of children and families. A consent executed in accordance with the provisions of this section shall be final and irrevocable from date of execution.
The form of such consent shall be as follows:—
I, as the (relationship) of (name of child), age , of the sex, born in (place of birth), on (date of birth), do hereby voluntarily and unconditionally surrender (child) to the care and custody of (agency or person receiving custody) for the purpose of adoption or such other disposition as may be made by a court of competent jurisdiction. I waive notice of any legal proceeding affecting the custody, guardianship, adoption or other disposition of (child).
I UNDERSTAND THAT THIS SURRENDER IS FINAL AND CANNOT BE REVOKED.
/s/ (person giving consent)
On this day of (insert year), before me personally came and appeared and in my presence duly executed the foregoing instrument, and (he, she) acknowledged to me that (he, she) executed the same as (his, her) free act and deed, fully cognizant of its irrevocability.
Date
State of
Notary Public
County of
Signed by (name of person giving consent) as (his, her) freely executed consent in the presence of each of us, and of each other, who thereafter have hereunto signed our names as witnesses.
/s/
Address
/s/
Address
Any surrender given outside of the commonwealth shall be valid for the purpose of this section if it was taken in accordance with laws of the state or the country where it was executed.
If an agency or person receiving a child born out of wedlock for purposes of a subsequent adoption receives from the child's mother an executed consent form as prescribed by this chapter, and no person has acknowledged paternity of the child in accordance with chapter two hundred and nine C or has been adjudicated the father of the child by any court of competent jurisdiction, then the person or agency shall request that the mother voluntarily provide a sworn written statement, executed before a notary and in the presence of two competent witnesses, one of whom shall be selected by the mother, that identifies the child's father and his current or last known address. Any such statement shall be used solely for the purpose of notifying the person named as the father of the status of the child.