Ad 2 - California Department Of Social Services - State Of California

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original for Court Record
Certified Copy for State Department of Social Services
IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF_____________________
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In the Matter of the Petition of
STEPPARENT ADOPTION
Consent to Adoption by Parent
______________________
Petitioner
Retaining Custody
I, the undersigned, being the parent of _________________________________________________________ give my full and
Name of Minor
free consent to the adoption of said child by _________________________________________________________________ , who is
Name of Petitioner (Stepparent)
my husband/wife/domestic partner without relinquishing any of my rights, duties, obligations as his/her parent, and I respectfully ask
that the petition be granted.
Said child was born on __________________________________ in ___________________________________and is the child
Date
City and State
of __________________________________________________________and __________________________________________________________
Name of Legal Parent
Name of Legal Parent
Date_________________________ 20 ______
_________________________________________________
Signature of Parent
Signed in the presence of
___________________________________
*Title
* The Clerk of the Superior Court, the Probation Officer, or, where stepparent investigations are delegated to County Welfare
Departments, a County Welfare Department Staff member may witness.
This form for use only when person giving consent is husband or wife of petitioner or domestic partner, as defined in Family
Code Section 297, of petitioner.
Original for court record, certified copy to be sent immediately to California Department of Social Services, Sacramento.
AD 2 (6/02)

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