WPCK  
           fwFM.!d@`S'p^󧰥ެmax8#}s4tuAi/L:[*"*^_.h|Gڜ](HAˤ2e4ob|Ù@nQDïp,MґsZE
He FMdhl&=zoI^JyԎW?l(WQH;/`f4$fiXFpĉ.
P&3Y4EB$r.')x/XjBWd(!Ҁ)h/A=quW|.y~0=_߶LlJ9b2:M>.r^"ǳ0A^ZaH9MYu|Gk%P>,H.6iePϐȥi'ceVgkt4O9 oF~ W            U   >             0   o  	  0   l    0   i    0   c    0   `  U  0   ]    0   Z    0   T  l  0   Q    0   ]    0   Z  n  0   W    0   Q    0   N  p  0   K    0   H  	  0   B  Q  0   ?     0   \  !  0   Y  .#  0   V  $  0   P  %  0   M  -'  0   J  z(  0   G  )  0   A  +  0   >  L,  0      -  0      $.  0       /  0(   c   /  0      ?0  	1   e   0  	7      Y1        g1  0      w1  #     2   U
   N   4  	%      (5  M      .5     (   25  N      Z5  	1   u   \5  	7   2   5  ^      6  w      6  4      6        '6  	m      )6  0      @6  0      6  0^      7  	1   {   ?8   U   >   8  0   U   8        M9   U   @   ):   b      i:  0      :  0      `;  0      <  0      <  0      =  0      8>  0      >  0      ?  0      @  0      @  0      A  0      RB  0      B  0      C  0      5D  0      D  0      YE  0      E  0      F  0      dG  0      H  0      H  0      PI  0      I  0      zJ  0      K   \	  	   `  & T i m e s   N e w   R o m a n          '                                 I N   T H E   D I S T R I C T   C O U R T   O F   M I T C H E L L   C O U N T Y ,   K A N S A S                                                                                                                                                                                                                                                                                                                                                                                                                                 
       *     C a r o l   S u e   M i l l e r   & 0    M i c k e y   E d w a r d s   
 .      
       
       
           2      +          0 _ l e v e l 1            , q  g !     p `	 P
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   
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 
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 @ 0              p ` P @ 0          ! "q         2   }             0 _ l e v n l 4             e  [ `	 `	 `	 P
 @ 0              p ` P @ 0          ! "e 2     3
   
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 
 
 @ 0              p ` P @ 0          ! "b 2     3
   
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   
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   
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   
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 S  I < < <         p ` P @ 0          ! "S 2     3
   
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      
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  <   D   L , 2     3
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  <   D   L ,             *   5   +       5   ( _ 2 4         )   	  <   D   L ) 2     3
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       . .    #      D   L #         *   ,   +       ,   ( _ 2 1               D   L   2     3
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       . .         L          *   >          >   ( _ 1 7           2  (   4 
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  <   D   L 2           *   D          D   ( _ 1 6             ,  " 

 
  <   D   L , 2     3
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 Ԁ,  " 

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  <   D   L ,             *   5          5   ( _ 1 5         )   	  <   D   L ) 2     3
   
 Ԁ)   	  <   D   L )         *   2          2   ( _ 1 4        `	 &   < <   D   L & 2     3
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 Ԁ&   < <   D   L &    `	     *   /          /   ( _ 1 3         #      D   L # 2     3
   
 Ԁ#      D   L #         *   ,          ,   ( _ 1 2               D   L   2     3
   
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   
 Ԁ   D D   L     h     *   &          &   ( _ 1 0               L  2     3
   
 Ԁ      L          (   #          #   & _ 9              L  2     3
   
 Ԁ     L          (   >          >   & _ 8           2  (   4 
  <   D   L 2 2      3
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 2  (   4 
  <   D   L 2           (   D          D   & _ 7             ,  " 

 
  <   D   L , 2     3
   
 ,  " 

 
  <   D   L ,             (   5          5   & _ 6         )   	  <   D   L ) 2     3
   
 )   	  <   D   L )         (   2          2   & _ 5        `	 &   < <   D   L & 2     3
   
 &   < <   D   L &    `	     (   /          /   & _ 4         #      D   L # 2     3
   
 #      D   L #         (   ,          ,   & _ 3               D   L   2     3
   
       D   L           (   )          )   & _ 2        h    D D   L  2     3
   
    D D   L     h     (   &          &   & _ 1               L  2     3
   
       L          &   #          #   $ _              L  2     3
   
      L      
 &  l!    .  .                  (  X  X  X( X      X  X  X( X     _         <      8 (  P( %	 %       d                  d  8 @    VV)  184   	 ^           u  a      	 
 | l \ L < ,           | l \ L < ,   !!   Xu    
     
        =      X   X       d                 d=   :        @    VV  INTHEDISTRICTCOURTOF____________COUNTY,KANSAS   Ly   X X    	 D    #   X  X  LyR  # INTHEINTERESTOF:              	 	   ______________________________                         0     0    (#(# 0    p(#(# 0    `p(#p(# 0    P`(#`(# CaseNo.______________    
~ P(#P(#  DOB 8  X  X  X X xx#   X  X  X8 X  # / 8  X  X  X X xx#   X  X  X8 X(  # /____A&male&female                                  p     `     P     @     0                                  F      	 d           Ly   X X  @     @    @     @    @    @    F    @    @    @    @  p  @  `	  @  P
  @  @  @    @    @    @  p  @  `	  @  P
  @  @  @  0  @     @    @     @    @      X  X  Ly CONSENTTOAPPOINTMENTOFPERMANENTCUSTODIAN#   Ly   X X  #    	 b	      X  X  Ly PursuanttoK.S.A.382268#   Ly   X Xy  #    	 H	
           D   Ly  6      X  X  D    X  X  X X            6          #   Ly   X X  #    X  X  Ly NOTICETOPARENT:#   Ly   X X  #          X  X  Ly Thisisanimportantlegaldocument.Whenyousignthisconsent,   	 K
   apermanentcustodianwillbeappointedforyourchild.Thepermanentcustodianshall   	 1   exercisealloftherightsandresponsibilitiesofaparent,exceptconsenttoadoptionoras   	    limitedbytheCourt.Youarestillresponsibleforpayingchildsupport. 6       ݌   	    Ќ        D   X X    D   D 	      6      X  X  D    X  X  X X                6  V         6  V     ݌̌        D   X X    D   D 	      6      X  X  D    X  X  X X            6  [         6  [     ݌̌        D   X X    D   D 	      6      X  X  D    X  X  X X           *    r     !*  6  N            r Mynameis____________________andIamthe&mother&fatherofthechildnamed   	 Q   aboveandIstatetotheCourt: 6  N     ݌   	 7   Ќ        D   X X    D   D 	      
7                   ( j        9                                3                            -                    " !  3                   "     #   Ly   D1	  #    X  X  Ly  !  3   2  j      1
   
 .3
   
 0    r      Mychild,namedabove,wasbornon_____________________inthe________________   	 {   HospitalintheCityof____________________________,Stateof_________________. !  3     ݌    a r(#r(#  Ќ	     " !  3                  "      !  3_   2  j      2
   
 .3
   
 0    r      Ipresentlyresideat򀀀. !  3_     ݌    G r(#r(#  Ќ	     " !  3                  "      !  3   2  j      3
   
 .3
   
 0    r      Iam_____yearsofageandwasbornon______________________. !  3     ݌    - r(#r(#  Ќ	     " !  3                  "      !  3   2  j      4
   
 .3
   
 0    r      IunderstandthatmyparentalrightsarenotbeingterminatedandIcanbeorderedtopay   	    childsupportandmedicalsupportformychild. !  3     ݌     r(#r(#  Ќ	     " !  3                  "      !  3$   2  j      5
   
 .3
   
 0    r      IunderstandthattoexerciseanyrightsIstillhaveImustkeepthecourtuptodateabout   	    howtocontactme,withmycurrentaddressandtelephonenumber. !  3$  Q   ݌    g r(#r(#  Ќ	     " !  3                  "      !  3   2  j      6
   
 .3
   
 0    r      Iunderstandthatifmychildiseverplacedforadoption,thecourtwilltrytoletmeknow   	 M   byusingtheinformationIhavegiventhem,andifmyaddressandtelephonenumberare   	  3   notuptodateImightnotknowifmychildisplacedforadoption. !  3     ݌    w! r(#r(#  Ќ	     " !  3                  "      !  3   2  j      7
   
 .3
   
 0    r      IunderstandthatifIwantinformationaboutmychildshealthoreducationIwillhaveto   	 ]"   keepthecourtuptodateabouthowtocontactme,becausetheinformationwillbesentto   	 C#    thelatestaddressthecourthas. !  3     ݌    )$! r(#r(#  Ќ	     " !  3                  "      !  3R   2  j      8
   
 .3
   
 0    r      IunderstandthatImaybeabletohavesomecontactwithmychild,butonlyifthe   	 %"   permanentcustodiandecidesitisinthechildsbestinterestsandifthecourtallowsthe   	 %#   contact. !  3R     ݌    &} $ r(#r(#  Ќ	     " !  3                  "      !  3   2  j      9
   
 .3
   
 0    r      Iunderstandthatunlessthecourtordersdifferently,thepermanentcustodianhastheright   	 'c!%   tomakethefollowingdecisionsaboutmychild:theamountandtypeofcontactIhavewith   	 (I"&   mychild;consenttomychildsmarriage;consenttomedicaltreatmentformychild;   	 )/#'   consenttomentalhealthtreatmentformychild;consenttoplacementofmychildina   	 s*$(   
    
 psychiatrichospitaloraninstitutionforthedevelopmentallydisabled;consentto   	 Y+$)   behavioralandmedicalexperiments;consenttosterilizationandconsenttowithholding   	 ^      lifeprolongingmedicaltreatment. !  3  +   ݌    D  r(#r(#  
    
 	     " !  3 	                 "      !  3   2  j      10
   
 .3
   
 0    r      Iunderstandthisconsentisfinal. !  3     ݌    * r(#r(#  Ќ	     " !  3 
                 "      !  3u    2  j      11
   
 .3
   
 0    r      Iunderstandthepermanentcustodianwillhavefullauthorityandalltherightsofabirth   	 	   parentorlegalguardianoverthechild,exceptthepowertoplacethechildforadoptionand   	 	   giveconsenttoadoption,andasotherwiselimitedbythecourt. !  3u       ݌    
~ r(#r(#  Ќ	     " !  3                  "      !  3a"   2  j      12
   
 .3
   
 0    r      Iconsenttotheappointmentofapermanentcustodianbythecourt. !  3a"  "   ݌    d r(#r(#  Ќ	     " !  3                  "      !  3o#   2  j      13
   
 .3
   
 0    r      IhavereadandunderstandtheaboveandIamsigningitasmyfreeandvoluntaryact. !  3o#  #   ݌    J r(#r(#  Ќ	     .    !  r     .  6      X  X  X X    X  X  X X            6  $        Datedthis_______dayof_________________,20_____,intheCityof__________________,   	 t	   Countyof______________,StateofKansasat____:____&a.m.&p.m. 6  پ$  #%   ݌   	 Z
   Ќ        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  &         6  ك&  &   ݌̌        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  w'                           p     `	     P
 0    @ 0    0@(#@(# 0     0(#0(# 0     (# (# 0     (#(# 0     (# (# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    p(#(# _____________________________ 6  w'  '   ݌     p(#p(#  Ќ        X  X  X X 	     )   Ly   XX  X X  )  6      X  X  Ly            6  *             0     0    (#(# 0    p(#(# 0    `	p(#p(# 0    P
`	(#`	(# 0    @P
(#P
(# 0    0@(#@(# 0     0(#0(# 0     (# (# 0     (#(# 0     (# (# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    p(#(# SignatureofParent 6  *  M*   ݌     p(#p(#  Ќ        Ly   X X 	     %   X  X  XX  Ly%  6      X  X  X X    X  X  X X            6  ,            CERTIFICATEOFATTORNEY 6  ٔ,  ,   ݌   	 ,   Ќ        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  -              ;  X  X  X X      Iamalicensedattorneyrepresenting#   X  X  X; X\.  # #   Ly   X Xl,  #    X  X  Ly Ԁtheparentnamedaboveandhaveexplainedtothat   	 V   parentthatbysigningthisconsentthecustodianwillexerciseallparentalrightstothechild,   	 <   excepttherighttoconsenttoadoption,andthatparentconfirmedthatintentionanddesire. 6  -  1.   ݌   	 "   Ќ        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  ٯ0         6  ٯ0  1   ݌̌        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  1        Date:_______________)   Ly   XX  X X.  )       0     0     (#(# 0     (# (# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    p(#(# _________________________ 6  ١1  2   ݌     p(#p(#  Ќ        X  X  Ly 	      6      X  X  X X            6  3             0     0    (#(# 0    p(#(# 0    `	p(#p(# 0    P
`	(#`	(# 0    @P
(#P
(# 0    0@(#@(# 0     0(#0(# 0     (# (# 0     (#(# 0     (# (# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    p(#(# SignatureofAttorney 6  3  4   ݌     p(#p(#  Ќ        X  X  X X 	     %   X  X  XX  X X%  6      X  X  X X    X  X  X X            6  V6                       0    p 0    `	p(#p(# 0    P
`	(#`	(# 0    @P
(#P
(# 0    0@(#@(# 0     0(#0(# 0     (# (# 0     (#(# 0     (# (# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    (#(# 0    p(#(# _        S.Ct_        .#_________________ 6  V6  6   ݌     p(#p(#  Ќ        X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X            6  9                           p     `	     P
     @     0        6  9  s9   ݌̌        X  X  X X 	     )   X  X  XX  X X16  )  6      X  X  X X            6  w:         6  w:  :   ݌̌        X  X  X X 	     %   X  X  XX  X X%  6      X  X  X X    X  X  X X            6  P;         ;  X  X  X X  6  P;  ;   ݌̌      ;  X  X  X; X 	     ) ;  X  X  XX  X; X+;  )  6    ;  X  X  X; X            6  l<        @    )
)
  CERTIFICATEOFATTORNEYFORMINORPARENT 6  l<  <   ݌   	 x!   Ќ      ;  X  X  X; X 	     % ;  X  X  XX  X; X% '         !'           Iamalicensedattorneyrepresenting#   X  X  X; X;  # theparentnamed ;  X  X  X X # ;  X  X  X; X{=  # Ԁabove,whoisaminor.Ihavefully   	 D#    explainedthatbysigningthisconsenttoappointmentofapermanentcustodianthatparentis   	 *$!   permanentlygivingupallparentalrightstothechild#   X  X  X; X9>  # ,excepttherighttoconsenttoadoption, ;  X  X  X X    	 %"   andthatparenthasconfirmedthatintentionanddesire.Iwaspresentattheexecutionofthis   	 %#   consent.   	 &~ $   3        z p (#    3 #   X  X  X; X⭫?  # Date:_______________ ;  X  X  X X 0    z 0    pz(#z(# _____________________________    (J"& p(#p(#       0     0    (#(# 0    z(#(# 0    pz(#z(# SignatureofAttorney    )0#' p(#p(#       0     0    (#(# 0    z(#(# 0    pz(#z(# _        S.Ct_        .#_______________    t*$( p(#p(#       #   X  X  X; X@  #                    z     p    	 @,%*    6      X  X  X X    X  X  X X               6  C        ACKNOWLEDGMENTBEFOREJUDGEOFDISTRICTCOURT 6  C  C   ݌   	 ^      Ќ       X  X  X X    X  X  X X 	     @    *   6      X  X  X X    X  X  X X           6  }D         6  }D  D   ݌̌       X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X          ?        z h p (#     z p?  6  pE        STATEOFKANSAS0     0    z(#(# 0    hz(#z(# ) 6  pE  F   ݌    	 h(#h(#  Ќ       X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X           6  G             0     0    (#(# 0    z(#(# 0    hz(#z(# )ss: 6  G  iG   ݌    	 h(#h(#  Ќ       X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X           6  qH        COUNTYOF__________________0    h ) 6  qH  H   ݌    
~ h(#h(#  Ќ       X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X           6  I         6  ٫I  J   ݌̌       X  X  X X    X  X  X X 	      6      X  X  X X    X  X  X X           6  J             I,__________________________,JudgeoftheDistrictCourt,______________Judicial   	 J   District,herebycertifythat_____________________________,knowntometobethesame   	 0   personwhosenameissubscribedtotheforegoingconsent,appearedbeforemethisdayin   	 t	   personandacknowledgedtheconsentanditwasafreeandvoluntaryact. 6  ٞJ  K   ݌   	 Z
   Ќ       X  X  X X 	      6      X  X  X X           6  M         6  M  aM   ݌̌       X  X  X X 	      6      X  X  X X    X  X  X X           6  M             Ihavefullyexplainedthatbysigningsuchconsentthecustodianwillexerciseallofthe   	 &
   parentalrightstosuchchildasexplainedintheconsentformandtheparentexecutingthis   	    consentconfirmedthatintentionanddesire. 6  M  4N   ݌   	    Ќ       X  X  X X 	      6      X  X  X X    X  X  X X           6  O         ;  X  X  X X Dated򀀀,at򀀀:#   X  X  X; XSP  #  8  X  X  X X 0#   X  X  X8 XP  #  ;  X  X  X X Ԁa.m.#   X  X  X; X'Q  #  8  X  X  X X 0#   X  X  X8 XrQ  #  ;  X  X  X X Ԁp.m.#   X  X  X; X⭻Q  #     p    	 `        0     0    (#(# 0    z(#(# 0    hz(#z(# 0    ph(#h(# 0 @  ph(#h(# 0 @  p(#(# 0 @  p(#(# ______________________________ 6  O  4P   ݌    F p(#p(#  Ќ       X  X  X X 	      6      X  X  X X           6  SS             0     0    (#(# 0    z(#(# 0    hz(#z(# 0    ph(#h(# 0 @  p (# (# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# 0 @  p(#(# JudgeoftheDistrictCourt 6  SS  S   ݌    , p(#p(#  Ќ       X  X  X X 	      6      X  X  X X           6  \U                           z     h     p  6  \U  U   ݌̌       X  X  X X 	          6      X  X  X X               6  dV         ;  X  X  X X OR 6  dV  V   ݌   	 V   Ќ     ;  X  X  X; X 	     _        ACKNOWLEDGEMENT_        ԀBEFORENOTARYPUBLIC   	 "       STATEOFKANSAS0     0    z(#(# 0    hz(#z(# )     h(#h(#                     z     h )ss:   	 v   COUNTYOF򀀀)   	 \      W            Icertifythat򀀀,knowntometobethesamepersonwhose   	 (   nameissubscribedtotheforegoingrelinquishment,appearedbeforemethisdayinpersonand   	 l    acknowledgedthat(she)(he)signedsuchrelinquishmentas(her)(his)freeandvoluntaryact,for   	 R!   thespecifiedpurpose.   	 8"   Dated򀀀,at򀀀:#   X  X  X; XV  #  8  X  X  X X 0#   X  X  X8 X[  #  ;  X  X  X X Ԁa.m.#   X  X  X; XX[  #  8  X  X  X X 0#   X  X  X8 X⭣[  #  ;  X  X  X X Ԁp.m.    p    	 $!                      z 0    h 0    ph(#h(# _____________________________    $" p(#p(#                     z     h 0    p Notary    %r# p(#p(#  MyCommissionExpires:___________________.#   X  X  X; X[  #    	 '>!%                      z     h     p    	 ,%*    (  X  X  X X    Authority   	 ^        ^   K.S.A.382268.   	 *   @    $  NotesonUse   	 
~        Withtheconsentoftheguardianadlitemandthesecretary,aparentmayconsentto   	 J   appointmentofapermanentcustodianpriortoahearingtoconsidertheterminationofparental   	 0   rights.Theparentmayconsenttotheappointmentofthesecretaryoranindividualaspermanent   	 t	   custodian.Whentheconsentistothesecretary,thesecretarymayplacethechildinthe   	 Z
   permanentcustodyofanindividualwhoisappointedpermanentcustodian.   	 @	             Theconsentshallbeacknowledgedbeforeajudgeoranotary.Iftherelinquishmentis   	 &
   acknowledgedbeforeajudge,itshallbethedutyofthecourttoadvisetheconsentingparentof   	    theconsequencesoftheconsent.#   X  X  X( X]  #  (  X  X  X X K.S.A.382272(f)listsconsequencesoftheconsent.Ifa   	    parentconsentstoappointmentofapermanentcustodianbasedonabeliefthattheotherparent   	 z   wouldsoconsentorbefoundunfit,andneitheroccurs,theconsentshallbenullandvoid.A   	 `   consentisfinalwhenexecuted,unlesstheconsentingparentprovesbyclearandconvincing   	 F   evidence,priortotheappointmentofapermanentcustodian,thattheconsentwasnotfreelyand   	 ,   voluntarilygiven.K.S.A.382272(g).   	 p        K.S.A.382272providesthatthesecretaryscustodyofthechildshallceaseandthe   	 V   courtmay,butisnotrequiredto,terminatejurisdictionoverthechilduponappointmentofthe   	 <   permanentcustodian.Ifanorderterminatingjurisdictionisnotentered,thecourtmayimpose   	 "   limitationsorconditionsupontherightsandresponsibilitiesofthepermanentcustodian,someof   	    whicharesetoutinK.S.A.382272(d).Thoselimitationsorconditionsshallbesetoutinthe   	    orderofappointment.   	 v        IfthepersoncannotreadandunderstandEnglish,specificallystatehowtheywere   	 \   informedofalltheirrightsandtheconsequencesofthisconsent.   	 B        K.S.A.382205(b)(2)requiresanattorneybeappointedforaminororparentandwhen   	 (   theparentismentallyillorotherwisehasadisablingcondition.#   X  X  X( Xb  #    	 l          (  X  X  X X #   X  X  X( Xh  # 
