Form Ad 868 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
(Alleged Natural Father in California)
(NAME OF CHILD’S 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, ____________________________________ having been alleged to be the father of __________________________________________
(NAME OF ALLEGED NATURAL FATHER)
(NAME OF CHILD)
a minor __________ child, born on ________________________ in ________________________________________ do hereby relinquish
(GENDER)
(DATE)
(CITY)
(STATE)
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, 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 ALLEGED NATURAL FATHER)
The foregoing relinquishment was signed on______________________ by __________________________________________________
(DATE)
(NAME OF ALLEGED NATURAL FATHER)
in the presence of:
(SIGNATURE OF WITNESS)
(NAME OF WITNESS)
(SIGNATURE OF WITNESS)
(NAME 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 whose signature is affixed above, in my presence, and in a language understood by the parent.
(DATE)
(SIGNATURE OF JUDGE)
(SUPERIOR COURT)
AD 868 (8/14)
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