Form Ad 583 Relinquishment In Or Out-Of-County
Download a blank fillable Form Ad 583 Relinquishment In Or Out-Of-County in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ad 583 Relinquishment In Or Out-Of-County with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
In or Out-of-County
(Presumed Father Denies He is the Birth 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, _______________________________, being presumed by law to be the father of ______________________________,
(NAME OF PRESUMED FATHER)
(NAME OF CHILD)
a minor
child, born____________in____________________, _____________, declare I am not the birth father
________________
(CITY)
(GENDER)
(DATE)
(STATE)
and do hereby relinquish and surrender 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 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. I declare that I am not the birth father of the child and am executing this relinquishment to
adoption solely for the purpose of promoting the welfare of the child by facilitating the child’s placement for adoption.
_________________________________
_________________________________________
(SIGNATURE OF PRESUMED FATHER)
(DATE)
The foregoing relinquishment was signed on __________ by __________________________________in the presence of:
(NAME OF PRESUMED FATHER)
(DATE)
(SIGNATURE OF WITNESS)
(NAME OF WITNESS)
(NAME OF WITNESS)
(SIGNATURE OF WITNESS)
STATE OF CALIFORNIA
}
COUNTY OF ___________________________________
ss.
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
(NAME OF PRESUMED FATHER)
person whose name is subscribed to the within instrument and acknowledged to me that he executed the same.
___________________________________________
__________________________________________
(TITLE)
(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)
AD 583 (ENG) (5/15) REPLACES AD 585
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal