NO. __________

(Supreme Court or COURT OF APPEALS, DIVISION __)

OF THE STATE OF WASHINGTON

IN RE DEPENDENCY OF:

A.B.C.,

A Minor Child.

NOTICE OF INTENT TO DELIVER CONSENT TO ADOPTION

TO: (Names of persons entitled to notice and their attorneys. See RAP 18.13A(k)).

Respondent, (Department of Social and Health Services, name of supervising agency), hereby gives notice that it intends to deliver a consent to the adoption of the above named child to prospective adoptive parents on the _____day of ________, 20___. See RAP 18.13A(k).

Dated this ____ day of _____, 20___.

______________________________

Signature

(Name of attorney)

Washington State Bar Association membership number

Attorney for Respondent

[Adopted effective April 3, 2012]