(a) A consent to terminate and transfer parental rights must contain all of the following:
(1) The date, place, and time of the execution of the consent.
(2) The name, date of birth, and current mailing address of the individual executing the consent.
(3) The date of birth and the name or pseudonym of the child.
(4) The name, address, and telephone number of the agency to which parental rights are being transferred.
(5) Information regarding the birth parent's right to file a notarized statement under § 923(b) of this title regarding the child's access to identifying information regarding the birth parent, if the child is adopted.
(6) A statement that the individual executing the consent understands that after the consent is signed and confirmed under § 1106(d) and (e) of this title, it is final and may not be revoked or set aside unless the requirements under § 1106B(a) or (b) of this title have been met.
(7) A statement that the individual executing the consent understands that the termination will extinguish all of that individual's parental rights and obligations with respect to the child, except for arrearages of child support.
(8) A statement that the individual executing the consent has received a copy of the consent.
(9) A statement that the individual executing the consent has not received or been promised money or anything of monetary value for the consent.
(b) A consent may contain 1 or more of the following statements:
(1) The consenting individual waives notice of a proceeding for termination of parental rights under § 1107A of this title.
(2) The consent may be revoked if at least 1 of the following occur:
a. Another consent is not executed within a specified period.
b. A court denies the termination of the other parent's rights in the child.
c. Another condition occurs as agreed upon by each party.