West Virginia Code
Article 22. Adoption
§48-22-303. Content of Consent or Relinquishment

(a) A consent or relinquishment as required by the provisions of section 22-301 must be written in plain English or, if the person executing the consent or relinquishment does not understand English, in the person's primary language. The form of the consent or relinquishment shall include the following, as appropriate:
(1) The date, place and time of the execution of the consent or relinquishment;
(2) The name, date of birth and current mailing address of the person executing the consent or relinquishment;
(3) The date, place of birth and the name or pseudonym ("Baby Boy _____ or Baby Girl _____") of the minor child;
(4) The fact that the document is being executed more than seventy-two hours after the birth of the child;
(5) If a consent, that the person executing the document is voluntarily and unequivocally consenting to the transfer of legal and physical custody to, and the adoption of the child by, an adoptive parent or parents whose name or names may, but need not be, specified;
(6) If a relinquishment, that the person executing the relinquishment voluntarily consents to the permanent transfer of legal and physical custody of the child to the agency for the purposes of adoption;
(7) If a consent, that it authorizes the prospective adoptive parents, or if a relinquishment, that it authorizes the agency, to consent to medical treatment of the child pending any adoption proceeding;
(8) That after the consent or relinquishment is signed and acknowledged, it is final and, unless revoked in accordance with the provisions of section 22-305, it may not be revoked or set aside for any other reason;
(9) That the adoption will forever terminate all parental rights, including any right to visit or communicate with the child and any right of inheritance;
(10) That the adoption will forever terminate all parental obligations of the person executing the consent or relinquishment;
(11) That the termination of parental rights and obligations is permanent whether or not any agreement for visitation or communication with the child is subsequently performed;
(12) That the person executing the consent or relinquishment does so of his or her own free will and the consent or relinquishment has not been obtained by fraud or duress;
(13) That the person executing the consent or relinquishment has:
(i) Received a copy of the consent or relinquishment;
(ii) Been provided the information and afforded the opportunity to participate in the voluntary adoption registry, pursuant to the provisions of article 23-101, et seq.;
(iii) Been advised of the availability of counseling;
(iv) Been advised of the consequences of misidentifying the other birth parent; and
(v) If a birth mother, been advised of the obligation to provide the information required by the provisions of section seven of this article in the case of an unknown father;
(14) That the person executing the consent or relinquishment has not received or been promised any money or anything of value for the consent or relinquishment, other than payments authorized by the provisions of section fourteen-h, article two, chapter sixty-one;
(15) Whether the child is an "Indian child" as defined in the Indian Child Welfare Act, 25 U.S.C. §1903;
(16) That the person believes the adoption of the child is in the child's best interest; and
(17) That the person who is consenting or relinquishing expressly waives notice of any proceeding for adoption unless the adoption is contested, appealed or denied.
(b) A consent or relinquishment may provide explicitly for its conditional revocation if:
(1) Another person whose consent or relinquishment is required does not execute the same within a specified period;
(2) A court determines not to terminate another person's parental relationship to the child; or
(3) In a direct placement for adoption, a petition for adoption by a prospective adoptive parent, named or described in the consent, is denied or withdrawn.
(c) A consent or relinquishment shall also include:
(1) If a consent, the name, address, telephone and facsimile numbers of the lawyer representing the prospective adoptive parents; or
(2) If a relinquishment, the name, address, telephone and facsimile numbers of the agency to which the child is being relinquished; and
(3) Specific instructions on how to revoke the consent or relinquishment.