Form Ad 501 Relinquishment In Or Out-Of-County - California Department Of Social Services
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
In or Out-of-County
(Birth Mother/Biological Father/Presumed Father in California)
Complete this section before sending this form to an out-of-county agency that has been
requested to take the annexed relinquishment.
On this ______ day of ____________ , 20 ___,
the ________________________________________________________
(NAME OF AGENCY)
hereby signifies its willingness to accept the annexed relinquishment and to accept said minor child for adoption.
By __________________________________
(AUTHORIZED AGENCY OFFICIAL)
I, ________________________________ the mother/father of _____________________________ , a minor ______ child,
(NAME OF PARENT)
(NAME OF CHILD)
(GENDER)
born on ____________ , in __________________________________________________________________________
(CITY)
( STATE)
(DATE)
do hereby relinquish and surrender the child for adoption to__________________________________________________
(NAME OF AGENCY)
(
)
_________________________________________________________________________________________________
(TELEPHONE NUMBER)
(AGENCY ADDRESS)
an organization licensed by the California Department of Social Services or authorized by Welfare and Institutions Code
16130 to find homes for children and to place children in homes for adoption.
I am not naming the prospective adoptive parent(s) for my child.
I am naming the following person(s) as the prospective adoptive parent(s):
_________________________________________________________________________________________
(FULL NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S))
If my child is not placed in the home of the named person(s) or my child is removed from the home before the
adoption is completed, the agency will notify me. I will have 30 days from the date of the notice to rescind the
relinquishment, take no action or select another placement for my child. If I do not rescind the relinquishment
within the 30-day period, the agency may place the child in a home that the agency selects.
I fully understand that when this relinquishment is filed with and acknowledged by the California Department of Social
Services, all my rights to the custody, services and earnings of the child and any responsibility for the care and support of
the child will be terminated.
___________________________________
_________________________________________________________
(DATE)
(SIGNATURE OF PARENT)
The foregoing relinquishment was signed on _______________ by ____________________________ in the presence of:
(DATE)
(NAME OF PARENT)
(NAME OF WITNESS)
(SIGNATURE OF WITNESS)
(NAME OF WITNESS)
(SIGNATURE OF WITNESS)
STATE OF CALIFORNIA
}
ss.
COUNTY OF_________________________
On this ____ day of ________________________ , 20 _______, before me,____________________________________ ,
(NAME OF AUTHORIZED AGENCY OFFICIAL)
an authorized official of the _________________________________________________________________________ an
(NAME OF AGENCY)
organization licensed by the California Department of Social Services or authorized by Welfare and Institutions Code
Section 16130 to find homes for children and to place children in homes for adoption, personally
appeared_______________________________________ known to me to be the person whose name is subscribed to the
(NAME OF PARENT)
within instrument and acknowledged to me that he/she executed the same.
(TITLE)
(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)
AD 501 (6/14) – REPLACES AD 503 AND AD 921
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