Form Ad 862 Relinquishment Of An Indian Child Out-Of-State
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT OF AN INDIAN CHILD
Out-of-State
(Alleged Natural Father)
ROLL NUMBER OR OTHER EVIDENCE OF TRIBAL AFFILIATION
NAME OF CHILD’S TRIBE
Complete upper section before sending this form to an out-of-state
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.
Pursuant to California Family Code Section 8700(c), a licensed California adoption agency may not accept a relinquishment from a parent
not residing in California unless the child is already in the care of the licensed California adoption agency.
By
AUTHORIZED AGENCY OFFICIAL
I, _________________________________________, having been alleged to be the father of ____________________________________,
NAME OF CHILD
NAME OF ALLEGED NATURAL FATHER
a minor _____________child, born on __________________________ in ________________________________, do hereby relinquish the
GENDER
DATE
CITY, STATE
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
***COMPLETED BY NOTARY PUBLIC***
When the form is NOT BEING signed in the presence of any agency representative
The Notary Public must staple the Acknowledgment document to this form and sign and date below.
DATE
SIGNATURE OF NOTARY
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 862 (3/12)
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