Form Ad 594 Alleged Father'S Consent To Adoption (In Or Out-Of-California)
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ALLEGED FATHER’S CONSENT TO ADOPTION
Original: Court Record
Copy: Parent
(In or Out-of-California)
Copy: Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
_________________________________________________
PETITIONER(S)
I, __________________________________ , having been alleged to be the father of ____________________ ________
NAME OF CHILD
NAME OF ALLEGED FATHER
(Gender: M F ), born to __________________________________________________ on _______________________,
NAME OF MOTHER
DATE OF BIRTH
in ___________________________________________________ give my full and free consent to the adoption of said
PLACE OF BIRTH
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.
SIGNATURE OF ALLEGED 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 (CDSS or Delegated County Adoption Agency)
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 594 (3/15)
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