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Refusal To Give Consent To Adoption AD 20 - California
| Refusal To Give Consent To Adoption Form. This is a California form and can be used in Civil Kings Local County . |
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REFUSAL TO GIVE CONSENT TO ADOPTION INSTRUCTIONS: This form is to be completed by the mother or presumed father who refuses to consent to the adoption of his or her child. If the form is signed in California, Section A should be completed and witnessed by a representative of the California Department of Social Services (CDSS) or a California county adoption agency licensed by CDSS that investigates independent adoptions. If the form is signed outside of California, Section B should be completed and notarized by a Notary Public. COUNTY: Original: Court Record Copy: Parent Copy: Case Record ACTION NUMBER: I,__________________________________________, the mother or presumed father ___________________________________ (NAME OF CHILD) born on _________________________refuse to give my consent to the adoption of said child (CHILD'S BIRTHDATE) by_________________________________________________________. (NAME OF PETITIONER(S)) SECTION A SIGNED IN CALIFORNIA SIGNATURE OF PARENT COUNTY WHERE SIGNED DATE SIGNED CDSS DISTRICT OFFICE OR COUNTY ADOPTION AGENCY: SIGNATURE OF CDSS OR AGENCY REPRESENTATIVE SECTION B SIGNED OUTSIDE OF CALIFORNIA STATE OF ____________________________ ) ) COUNTY OF ___________________________ ) On ______________________________ before me, ______________________________________________________ , a Notary Public, personally appeared _________________________________________________ proved to me on the basis of satisfactory evidence to (NAME OF MOTHER/PRESUMED FATHER) be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. ____________________________________________ (Seal) Signature AD 20 (ENG/SP) (3/08) American LegalNet, Inc. www.FormsWorkFlow.com
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