California > Statewide > Department Of Social Services
Parental Consent To Adoption (In California) (Health And Human Services Agency) AD 1A - California
| Parental Consent To Adoption (In California) (Health And Human Services Agency) Form. This is a California form and can be used in Department Of Social Services Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF _____________________________ In the Matter of the Petition of Petitioner(s) } PARENTAL CONSENT TO ADOPTION (In California) I/we, _____________________________ being the parent(s) of _________________________________(Gender: M F) Name of Child born on ______________________________ in ______________________________________________ give my/our full and Date of Birth Place of Birth free consent to the adoption of said child by _____________________________________________________________________________________, Name(s) of Petitioner(s) I/we understand that I/we may revoke this consent only during the thirty (30) day period beginning on the date I/we sign this consent and only if I/we have not waived my/our right to revoke the consent. I/we further understand that with the signing of the order of adoption by the court I/we shall give up all my/our rights of custody, services, and earnings of said child and I/we may not reclaim said child. Signed in the presence of: SIGNATURE OF REPRESENTATIVE: CDSS or Delegated County Adoption Agency DATE CDSS DISTRICT OFICE OR COUNTY OFFICE SIGNATURE OF MOTHER ADDRESS DATE SIGNATURE OF FATHER TELEPHONE NUMBER FULL ADDRESS AD 1A (ENG/SP) (8/02) American LegalNet, Inc. www.USCourtForms.com
|
|||||||
