Agreement is made on ________________ (Date),
by and between ____________________________________, a married woman (Referred to as Surrogate),
________________________, her husband (Referred
to as Surrogate's Husband),
who both reside at ___________________________________________ (Address) and __________________________, (Referred to as Natural Father), who
resides at ____________________________________________________ (Address).
Agreement is made with reference to the following facts:
A. Natural Father is a married man over the
age of __________ (______) (Eighteen (18) or
Applicable Age Required by Statute) years who desires to enter into
this Agreement, the sole purpose of which is to enable the Natural Father and
his wife, who is infertile, to have a child who is biologically related to the
B. Surrogate and Surrogate’s Husband are over
the age of _________ (______) (eighteen (18))
years and both desire and are willing to enter into this Agreement subject to
the terms and conditions contained in this Agreement.
THEREFORE, in consideration of the mutual promises, representations, terms and
conditions contained in this Agreement, the parties agree as follows:
represents that she is capable of conceiving children. Surrogate understands and agrees that in the
best interests of the child she will not form or attempt to form a parent-child
relationship with any child or children she may conceive, carry to term, and
give birth to, pursuant to this Agreement.
and Surrogate's Husband have been married since _____________ (Date).
Surrogate's Husband agrees with the purposes and provisions of this
Agreement and acknowledges that his wife, Surrogate, shall be artificially
inseminated pursuant to the provisions of this Agreement. Surrogate's Husband agrees that in the best
interests of the child he will not form or attempt to form a parent-child
relationship with any child or children Surrogate may conceive by artificial
insemination, as described in this agreement, and agrees to freely and readily
surrender immediate custody of the child to Natural Father.
Husband further agrees to terminate his parental rights to such child.
Surrogate's Husband acknowledges he will do all acts necessary to rebut the
presumption of paternity of any offspring conceived and born pursuant to this
Agreement as provided by law, including blood testing and/or HLA testing.
shall be artificially inseminated with the semen of Natural Father by a
physician. Surrogate, upon becoming
pregnant, agrees she will carry the embryo (or
fetus) until delivery. Surrogate and Surrogate's Husband, agree
that they will cooperate with any background investigation into Surrogate's
medical, family, and personal history and warrants the information to be
accurate to the best of their knowledge and belief. Surrogate and Surrogate's Husband agree to surrender custody of
the child to Natural Father, to institute, and cooperate, in proceedings to
terminate their respective parental rights to such child, and to sign any and
all necessary affidavits, documents, and papers in order to further the intent
and purposes of this Agreement.
Surrogate and Surrogate's Husband understand that the child is being
conceived for the sole purpose of giving such child to Natural Father, its
natural and biological father.
Surrogate and Surrogate's Husband agree to sign all necessary affidavits
and other documents, prior to and subsequent to the birth of the child, and to
voluntarily participate in any paternity proceedings necessary for the Natural
Father's name to be entered on the child's birth certificate as the natural or
consideration for this Agreement which is compensation for services and
expenses, and should in no way be construed as a fee for the termination of
parental rights or as payment in exchange for a consent to surrender the child
for adoption, in addition to other provisions contained in this Agreement,
shall be as follows:
1. ____________ ($________) dollars shall be
paid to Surrogate, for services and expenses in carrying out Surrogate's
obligations under this Agreement, immediately upon surrender to Natural Father
custody of the child born pursuant to the provisions of this Agreement.
2. The consideration to be paid to Surrogate
shall be deposited with _____________ (Referred
to as Custodian), the representative of Natural Father, at the time
of the signing of this Agreement and shall be held in escrow until completion
of the duties and obligations of Surrogate as provided for in this Agreement.
3. Natural Father shall pay the expenses
incurred by Surrogate, pursuant to her pregnancy, which are specifically
defined as follows:
All medical, hospitalization, pharmaceutical, laboratory, and therapy expenses,
incurred as a result of Surrogate's pregnancy, not covered or allowed by her
present health and major medical insurance, including all extraordinary medical
expenses and all reasonable expenses for treatment of any emotional, mental, or
other problems related to such pregnancy.
In no event, however, shall any such expenses be paid or reimbursed
after a period of __________ (___) months has elapsed since the date of the
termination of the pregnancy. This
agreement specifically excludes expenses for lost wages or other non-itemized
incidentals related to such pregnancy.
Father shall not be responsible for any medical, hospitalization,
pharmaceutical, laboratory, or therapy expenses occurring __________ (_____)
months after the birth of the child, unless the medical problem incident to
such expenses was known and treated by a physician prior to the expiration of
the __________ (_____) month period and written notice advising of this
treatment is given to Custodian, as representative of Natural Father, by
certified mail, return receipt requested.
Father shall be responsible for the total cost of all paternity testing. Such paternity testing may, at the option of
Natural Father, be required prior to release of the Surrogate fee from
escrow. If Natural Father is conclusively
determined not to be the biological father of the child as a result of an HLA
test, this Agreement will be deemed breached and Surrogate shall not be
entitled to any fee, and Natural Father shall be entitled to reimbursement of
all medical and related expenses from Surrogate and Surrogate's Husband.
Father shall be responsible for Surrogate's reasonable travel expenses incurred
at the request of Natural Father pursuant to this Agreement.
and Surrogate's Husband are aware, understand, and agree to assume all risks,
including the risk of death, which are incidental to conception, pregnancy,
childbirth, and includes, but is not limited to, complications subsequent to
and Surrogate's Husband, hereby agree to undergo psychiatric evaluation by
_____________________________________, a psychiatrist, as designated by Natural
Father. Natural Father shall pay for
the cost of such psychiatric evaluation.
Prior to their evaluations, Surrogate and Surrogate's Husband shall sign
a medical release permitting dissemination to Custodian or Natural Father and
his wife copies of the report prepared as a result of such psychiatric
and Surrogate's Husband hereby agree it is the exclusive and sole right of
Natural Father to name such child born pursuant to this agreement.
as referred to in this agreement, shall include all children born
simultaneously pursuant to the inseminations contemplated in this Agreement.
the event of the death of Natural Father prior or subsequent to the birth of
such child, it is understood and agreed by Surrogate and Surrogate's Husband,
the child will be placed in the custody of Natural Father's wife.
the event the child is miscarried prior to the ______ (____) (Fifth or as the Case May Be) month of
pregnancy, no compensation, as enumerated in Section Four, Paragraph 1, shall
be paid to Surrogate. However, the
expenses enumerated in Section Four, Paragraph 3 shall be paid or reimbursed to
Surrogate. In the event the child is
miscarried, dies, or is stillborn subsequent to the _______ (_____) (Fourth or as the Case May Be) month of
pregnancy the Surrogate shall receive _____________ ($______) dollars in lieu
of the compensation enumerated in Section Four, Paragraph 1. In the event of a
miscarriage or stillbirth as described above, this agreement shall terminate,
and neither Surrogate nor Natural Father shall be under any further obligation
under this Agreement.
and Natural Father shall each undergo complete physical and genetic examination
and evaluation, under the direction and supervision of a licensed physician, to
determine whether the physical health and well-being of each is
satisfactory. Such physical examination
shall include testing for AIDS and venereal diseases including, but not limited
to, syphilis, herpes, and gonorrhea.
Such AIDS and venereal disease testing shall be done prior to, but not
limited to, each series of inseminations.
the event that pregnancy has not occurred within a reasonable time in the
opinion of Natural Father, this Agreement shall terminate by written notice to
Surrogate, at the residence provided to the Custodian by the Surrogate (from
Custodian, as representative of the Natural Father).
agrees she will not abort the child once conceived except if, in the professional
medical opinion of the inseminating physician, such action is necessary for the
physical health of Surrogate or the child has been determined by such physician
to be physiologically abnormal.
Surrogate further agrees, at the request of such physician, to undergo
amniocentesis or similar tests to detect genetic and congenital defects. In the event such test reveals the fetus is
genetically or congenitally abnormal, Surrogate agrees to abort the fetus on
demand of Natural Father. The fee paid
to Surrogate in this circumstance will be in accordance to Section Ten. If Surrogate refuses to abort the fetus upon
demand of Natural Father, Natural Father's obligations, as stated in this
Agreement, shall cease except as to obligations of paternity imposed by
Father recognizes that some genetic and congenital abnormalities may not be
detected by amniocentesis or other tests, and, therefore, if proven to be the
biological father, assumes the legal responsibility for any child who may
possess genetic or congenital abnormalities.
agrees to adhere to all medical instructions given her by the inseminating
physician as well as her independent obstetrician. Surrogate also agrees not to smoke cigarettes, drink alcoholic
beverages, use illegal drugs, or take prescription or nonprescription
medications without written consent from her physician. Surrogate agrees to follow a prenatal
medical examination schedule to consist of no fewer visits than: one (1) visit
per month during the first ____________ (____) (Seven or as the Case May Be) months of pregnancy, two (2)
visits (each to occur at two-week intervals) during the __________ (_____) and
_________ (______) (Eighth and Ninth or as
the Case May Be) months of pregnancy.
to signing this Agreement, each party has been given the opportunity to consult
an attorney of his or her own choice concerning the terms and legal
significance of the agreement and the effect it has upon any and all interests
of the parties to this Agreement.
party acknowledges that he or she has carefully read and understands every word
in this Agreement, realizes its legal effect, and is signing this agreement
freely and voluntarily. None of the
parties has any reason to believe the other party or parties did not understand
fully the terms and effects of this Agreement, or that the other parties did
not freely and voluntarily execute this Agreement.
the event any of the provisions of this Agreement are deemed to be invalid or
unenforceable, such invalid or unenforceable provision shall be deemed
severable from the remainder of this Agreement and shall not cause the
invalidity or UN-enforceability of the reminder of this Agreement. If such provision shall be deemed invalid
due to its scope or breadth, then such provision shall be deemed valid to the
extent of the scope or breadth permitted by law.
Agreement shall be executed in three copies, each of which shall be deemed an
original. One copy shall be given to
Custodian, another copy to Natural Father, and the third copy to Surrogate.
instrument embodies the entire Agreement of the parties with respect to the
subject matter of surrogate parenting.
There are no promises, terms, conditions, or obligations other than
those contained in this Agreement, and this Agreement shall supersede all
previous communications, representations, or agreements, either verbal or
written, among the parties.
Agreement cannot be modified except by written agreement signed by all the
Agreement has been drafted, negotiated, and executed and shall be governed by,
and enforced in accordance with, the laws of the State of
of Surrogate Mother Date
of Surrogate's Husband Date
of Natural Father Date