A. Every act of intent to surrender for adoption shall contain the following information:
(1) The name, parish of domicile, age, and marital status of the pregnant female anticipating adoption of her unborn child or of the mother of a child.
(2) The name and address of the alleged father of the child or expected child.
(3) The anticipated or actual birth date of the child.
(4) The court in which the act of intent to surrender for adoption will be filed.
B. The act of intent to surrender for adoption shall also recite the following declarations:
(1) Whether the act of intent to surrender for adoption is being executed prior to or after the birth of the child.
(2) That she has no mental incapacity and is under no interdiction that impairs her capacity to consent to the surrender of her child.
(3) That, if required by Article 1113, she is joined in the act of intent to surrender for adoption by her parents or tutor.
(4) That she has been informed and understands that the act of intent to surrender for adoption is only in anticipation of adoption and does not mean that she agrees to surrender the child.
(5) That she has been informed and understands that her rights as the parent of the child are not being terminated by execution of this act of intent to surrender for adoption.
(6) That she has been informed and understands that the act of intent to surrender for adoption is being executed for the purpose of determining whether the alleged father will oppose her plans for surrendering her child for adoption.
(7) That she has been informed and understands that if the alleged father responds by filing a timely written objection, he will receive notice of any motion for hearing to determine his parental rights that she may thereafter file or of any surrender she may thereafter execute and will be given notice of a hearing on his opposition and will be given an opportunity to present evidence to acknowledge his paternity, to demonstrate his fitness as a parent, and to demonstrate his commitment to the child.
(8) That she has been informed and understands that if the father does not respond by filing a timely written objection, that his potential parental rights may be terminated by the court upon the court's approval of her surrender.
(9) That she freely and voluntarily executes the act of intent to surrender for adoption and understands that she is not required to execute it and that failing to execute it will not prevent her from later deciding to surrender her child for adoption.
C. In a private adoption, the act of intent to surrender for adoption shall also recite that the pregnant female or mother has consulted with and been fully advised by an attorney about the meaning of these declarations and the consequences of the act of intent to surrender for adoption, other than the attorney, associate, partner, shareholder, or employee of the attorney's law firm or corporation for the prospective adoptive parent.
D. The act of intent to surrender for adoption shall be in authentic form and shall be dated and signed by the pregnant female or mother and her representative, if applicable. If required by Article 1113, it shall also be signed by the minor's parents or tutor, or the written consent of the court shall be attached.
E. The act of intent to surrender for adoption shall contain the requirements in substantially the following form:
"INTENT TO SURRENDER A CHILD FOR ADOPTION
STATE OF LOUISIANA"
PARISH OF (NAME OF PARISH)
BEFORE ME, the undersigned notary public, and in the presence of the two undersigned competent witnesses who are over the age of eighteen, personally came and appeared:
(NAME OF MOTHER)
a female of the age of (AGE), who is (MARITAL STATUS), and domiciled in the Parish of (NAME OF PARISH), who being first duly sworn, did depose and state:
(1) She is pregnant and expects to deliver a child on or about (EXPECTED DELIVERY DATE)
OR
[She is the mother of (CHILD'S NAME), born on (DATE OF BIRTH) in the (PARISH/COUNTY OF BIRTH), State of (STATE OF BIRTH).]
(2) The father of the child is [is believed to be] (FATHER'S NAME), and his address is (ADDRESS).
(3) To the best of her knowledge, the alleged father:
(a) Has not executed a notarial act of acknowledgment of the child.
(b) Has not admitted his paternity of the child by registering with the putative father registry.
(c) Has not informally acknowledged his paternity of this child.
(d) Has not had his paternity of this child established by court judgment.
OR
[The paternity of this child has been established by the judgment of the (NAME OF COURT) _________ on (DATE) finding that (FATHER'S NAME) is the father.]
(4) The court in which this act of intent to surrender for adoption is to be filed is (NAME OF JUVENILE COURT) located in (CITY AND PARISH OF COURT).
(5) Affiant declares that she has no mental incapacity and is under no interdiction that impairs her capacity to surrender the child.
(6) Affiant declares that she has been informed and understands that this act of intent to surrender for adoption is only in anticipation of adoption and does not mean that she agrees to surrender the child nor does her refusal to sign this intent to surrender for adoption prevent her from surrendering the child after birth for adoption.
(7) Affiant declares that she has been informed and understands that her rights as the parent of the child are not being terminated by execution of this act of intent to surrender for adoption.
(8) Affiant declares that she has been informed and understands that this act of intent to surrender for adoption is being executed for the purpose of determining whether the father will oppose her plans for surrendering her child for adoption.
(9) Affiant declares that she has been informed and understands that if the father responds by filing a timely written objection, he will receive notice of any motion for hearing to determine his parental rights that she may thereafter file or of any surrender she may thereafter execute, and will be given notice of a hearing on his opposition, and will be given an opportunity to present evidence to acknowledge his paternity, to demonstrate his fitness as a parent, and to demonstrate his commitment to the child.
(10) Affiant declares that she has been informed and understands that if the father does not respond by filing a timely written objection, that his potential parental rights may be terminated by the court upon the court's approval of her surrender.
(11) Affiant declares that she freely and voluntarily executes this act of intent to surrender for adoption.
(ADDITIONAL DECLARATIONS IF THE INTENT
TO SURRENDER IS FOR A PRIVATE ADOPTION)
(12) Affiant declares that she is eighteen years of age or older.
OR
[Affiant declares that she is under the age of eighteen and that (NAME OF PARENTS OR TUTOR) join in this act of intent to surrender for adoption.]
OR
[Affiant declares that she is under the age of eighteen and that (NAME OF JUVENILE COURT) located in (CITY AND PARISH OF COURT) has given its written consent for her execution of this act of intent to surrender for adoption.]
(13) Affiant declares that she has consulted with and been fully advised by an attorney about the meaning of these declarations and the consequences of this act of intent to surrender for adoption, other than the attorney for the prospective adoptive parent or an associate, partner, shareholder, or employee of the prospective adoptive parent's attorney's law firm or corporation.
Sworn to, signed, and notarized, after being carefully read and explained to (NAME OF MOTHER) in the presence of the undersigned notary and witnesses on this _____ day of _________, 20__.
_______________________________
AFFIANT MOTHER
WITNESSES:
______________________
______________________
(ADDITIONAL SIGNATURE(S) IN PRIVATE ADOPTION
IF THE MOTHER IS A MINOR)
________________________________
PARENT(S)/TUTOR OF MINOR MOTHER
______________________
NOTARY PUBLIC AND SEAL
(REQUIRED ADDITIONAL ATTACHMENT(S) IF THE ACT OF INTENT TO SURRENDER FOR ADOPTION IS FOR A PRIVATE ADOPTION:
(AFFIDAVIT OF ATTORNEY FOR MOTHER)
(REQUIRED ADDITIONAL ATTACHMENT IF THE SURRENDER IS BY A MINOR MOTHER WHOSE PARENT(S) OR TUTOR REFUSE TO JOIN IN THE INTENT TO SURRENDER FOR ADOPTION:
(WRITTEN CONSENT OF THE COURT)
Acts 2003, No. 564, §1; Acts 2004, No. 26, §3.