STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PRESUMED FATHER’S CONSENT TO ADOPTION
Original: Court Record
Copy: Parent
WHEN DENYING HE IS THE BIOLOGICAL FATHER (In or Out-of-California)
Copy: Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
_________________________________________________
PETITIONER(S)
I, __________________________________ , being presumed by law to be the father of ____________________ ______
NAME OF PARENT
NAME OF CHILD
(Gender: M F ), born to __________________________________________________ on ______________________,
NAME OF MOTHER
DATE OF BIRTH
in ___________________________________________________ declare that I am not the biological father of said child
PLACE OF BIRTH
and give my full and free consent to the adoption of said child by ___________________________________________.
NAME OF PETITIONER(S)
I understand that I may revoke this consent only during the thirty (30) day period beginning on the date I sign this consent
and only if I have not waived my right to revoke the consent. I further understand that with the signing of the order of adoption
by the court I shall give up all my rights of custody, services, and earnings of said child and I may not reclaim said child.
I declare I am not the biological father of said child and am executing this consent to adoption solely for the purpose of
promoting the welfare and best interest of said child by facilitating said child’s adoption by the petitioner(s).
SIGNATURE OF PRESUMED FATHER
DATE
FULL ADDRESS
SECTION A
C
mplete if Signed in California
O
I, ______________________________________________, a representative of _________________________________________,
NAME OF AGENCY REPRESENTATIVE
NAME OF CDSS OR DELEGATED COUNTY ADOPTION AGENCY
have witnessed the signing of this consent to adoption by the above-named parent on _________________________________ in
DATE
_________________________________________.
COUNTY WHERE SIGNED
TITLE OF AGENCY REPRESENTATIVE
SIGNATURE OF AGENCY REPRESENTATIVE
FULL ADDRESS
TELEPHONE NUMBER
SECTION B
C
mplete if Signed Outside of California*
O
*** THIS FORM MUST BE SIGNED BY A NOTARY PUBLIC WHEN SIGNED OUTSIDE OF CALIFORNIA***
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
*If signing outside the United States, this section must meet with the requirements of California Civil Code Section 1183
AD 165 (3/15) (combined with AD 166)
1
