Form Ad 504 Relinquishment Out-Of-State In Armed Forces - California Department Of Social Services
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1STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
Out-of-State in Armed Forces
(Birth Mother/Biological Father/Presumed Father)
Complete upper section before sending this form out-of-state
to have the annexed relinquishment taken.
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
(NAME OF PARENT)
(NAME OF CHILD)
_______ child, born on_______________________ in __________________________________ do hereby relinquish and surrender
(GENDER)
(CITY)
(STATE)
(DATE)
the child for adoption to _______________________________________________________________________________________
NAME OF AGENCY
(
)
___________________________________________________________________________________________________________
(AGENCY ADDRESS)
(TELEPHONE NUMBER)
an 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.
I am not naming the prospective adoptive parent(s) for my child.
I
I
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 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)
On this ________ day of _______________ , 20 _____, before me, ____________________________________________________
(NAME OF OFFICER)
the undersigned officer, personally appeared_______________________________________________________________________
(NAME OF PARENT)
known to me (or satisfactorily proven) to be (a) serving in the armed forces of the United States, (b) a spouse of a person serving in the
armed forces of the United States, or (c) a person serving with, employed by, or accompanying the armed forces of the United States
outside the United States and outside the Canal Zone, Puerto Rico, Guam and the Virgin Islands, and to be the person whose name is
subscribed to the within instrument and acknowledged that he/she executed the same. And the undersigned does further certify that
he/she is at the date of this certificate a commissioned officer of the armed forces of the United States having the general powers of a
notary public under the provisions of Section 936 or 1044a of Title 10 of the United States Code (Public Law 90-362 and 101-510) (Per
California Civil Code Section 1183.5).
Subscribed and sworn to before me on this _______ day of ___________________, 20_____.
(
SIGNATURE OF OFFICER AND SERIAL NUMBER, RANK
BRANCH OF SERVICE AND CAPACITY IN WHICH SIGNED.)
AD 504 (5/15)
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