Form Ad 866 Relinquishment Of 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 INDIAN CHILD
In or Out-of-County
(Presumed Father Denies He is the Birth Father in California)
NAME OF TRIBE
ROLL NUMBER OR OTHER EVIDENCE OF TRIBAL AFFILIATION
Complete upper 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 on ____________________ in ________________________________________________________ declare I
(GENDER)
(DATE)
(CITY)
(STATE)
am not the birth father 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 or 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. 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.
________________________________
____________________________________________________________________________
(DATE)
(SIGNATURE OF PRESUMED FATHER)
The foregoing relinquishment was signed on ____________________ by ______________________________________ in the presence of:
(DATE)
(NAME OF PRESUMED FATHER)
______________________________________________
________________________________________
(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, __________________________________________________,
(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_____________________________________________
(NAME OF PARENT)
known to me to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same.
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 who signature is affixed above, in my presence, and in a language understood by the parent.
SIGNATURE OF JUDGE
SUPERIOR COURT
DATE
AD 866 (10/14) REPLACES AD 873
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