Form Ad 864 Relinquishment Of An Indian Child In Or Out-Of-County
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT OF AN INDIAN CHILD
In or Out-of-County
(Birth Mother/Biological Father/Presumed Father in California)
NAME OF TRIBE:
ROLL NUMBER OR OTHER EVIDENCE OF TRIBAL AFFILIATION:
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
,
the mother/father of
, a minor
child,
I
___________________________
_____________________________________
______________
GENDER
NAME OF PARENT
NAME OF CHILD
born on ___________________ in _________________________do hereby relinquish and surrender the child for adoption to
DATE
CITY,
STATE
(
)
AGENCY ADDRESS
TELEPHONE NUMBER
NAME OF AGENCY
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, and the relinquishment will be binding with the signing of the decree of adoption unless I withdraw said
relinquishment before the decree of adoption is signed.
DATE
SIGNATURE OF PARENT
The foregoing relinquishment was signed on ________________ by __________________________________________in the
DATE
NAME OF PARENT
presence of:
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,
an authorized
____________________________________________,
NAME OF AUTHORIZED AGENCY OFFICIAL
official of the _________________________________________________________ an organization licensed by the California
NAME OF AGENCY
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
NAME OF PARENT
to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same.
TITLE
SIGNATURE OF AUTHORIZED AGENCY OFFICIAL
CERTIFICATION
The terms and consequences of the voluntary signing of the relinquishment, including the right to withdraw the relinquishment
prior to the signing of the decree of adoption were fully explained in detail to and understood by the parent of this Indian child.
The explanation was given by the agency representative whose signature is affixed above, in my presence, and in a language
understood by the parent.
SUPERIOR COURT:
DATE:
SIGNATURE OF JUDGE:
AD 864 (9/14)
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