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IVF Agreement and Statement
I the undersigned, _______________ (the woman), I.D.
number ____________, hereinafter to be known as “___________,” and
_______________ (the man), I.D. number ____________,
hereinafter to be known as “___________,” of our free will, after
having been cautioned per law that we must state the truth and that
otherwise we shall be liable to the penalties established in the
law, hereby state and stipulate the following:
1. We hereby proffer this Statement for the purpose of submitting it
to the In Vitro Fertilization Unit at ________ Hospital
(hereinafter: the “In Vitro Fertilization Unit”) in order to begin
in vitro fertilization (IVF) or insemination treatment.
2. We hereby stipulate that with mutual consent and willing free
choice and without any pecuniary consideration from any party
whatsoever, we have applied to the In Vitro Fertilization Unit in
order to perform in vitro fertilization from the semen of the man
and the ova of the woman.
3. ____________ states that he is interested in having ____________
be fertilized with his semen, agrees that this should be done, and
affirms his awareness that his obligations to the child shall be in
effect irrespective of the validity of this Agreement and shall
apply to him in any event, as a biological parent.
4. ____________ states that she is not a surrogate mother as this
term is defined in the Consent to Surrogate Motherhood
(Certification of Agreement and Status of Child) Law, 5757-1996.
5. ____________ and ____________ state that they are not married to
other spouses.
6. Additionally, we state that we know and understand that upon the
birth of the baby pursuant to this fertilization procedure, all
obligations and rights flowing from natural biological parentage
shall apply to us even if we are not married to each other at the
time birth is given.
7. Provided that no law states to the contrary, upon the death of
one of the Parties to this Agreement, their shared genetic material
shall become / shall not become the absolute property of the
surviving Party and s/he may do with it what s/he wishes.
8. Each of the Parties may at any time, by presentation of written
demand, enjoin the In Vitro Fertilization Unit from making any use
whatsoever of the shared genetic material. / The Parties hereby
advise the In Vitro Fertilization Unit that they may neither disavow
this Agreement nor demand that the In Vitro Fertilization Unit not
make use of the shared genetic material and, by so stating, the
Parties leave the decision on using the shared genetic material to
the other Party.
9. ____________ and ____________ state that this Agreement was not
executed in return for pecuniary or other consideration to any of
the Parties thereto.
In witness whereof, we affix our signatures in Tel Aviv:
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___________________
the woman
signature |
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___________________
the man signature |
Today: ___________________
I the undersigned, Gabriel Hanner, Attorney at Law, with offices at
242 Ben-Yehuda Street, Tel Aviv, hereby certify that
_______________, I.D. number ____________, and _______________, I.D.
number ____________, appeared before me on ______________
(date)and signed the foregoing Statement in my presence after I
cautioned them that they must state the truth and that otherwise
they shall be liable to the penalties established in the law.
_____________________________
Gabriel Hanner, Attorney at Law
This document was executed by
Hanner-Ofer Law Offices, 242 Ben-Yehuda St., 63501 Tel Aviv, Israel,
Tel. +9723 546 88 88, fax +9723 5466366, 5467536
Web-Site: www.Hanner.co.il E-Mail: [email protected]
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