STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original: Court Record
PARENTAL CONSENT TO ADOPTION
Copy:
Parent
(Outside California in the Armed Forces)
Copy:
Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
PETITIONER(S)
I, _____________________________________________________________________________ being the (Choose One):
NAME OF PARENT
Birth Mother
Presumed Father
Biological Father
Other Legal Parent_________________________________
I
I
I
I
I
I
of ______________________________________________________ (Gender:
M
F) born on ______________________
NAME OF CHILD
in ____________________________________________________ give my full and free consent to the adoption of said child by
PLACE OF BIRTH
,
______________________________________________________________________________________________________
NAME(S) OF PETITIONER(S)
I understand that I may revoke this consent ONLY DURING THE THIRTY (30) DAY PERIOD beginning on the date I sign this
consent and ONLY IF I HAVE NOT WAIVED MY RIGHT TO REVOKE THE CONSENT. I further understand that with the signing
of the order of adoption by the court I shall give up all my rights of custody, services, and earnings of said child and I may not
reclaim said child.
DATE
SIGNATURE OF PARENT
FULL ADDRESS
Witnessed By (pursuant to California Civil Code Section 1183.5)
On this the ______ day of ____________, 20____, before me ____________________________________________________
NAME OF OFFICER
the undersigned officer, personally appeared ______________________________________________________ known to me
NAME OF PARENT
(or satisfactorily
proven) to be:
1) Serving in the armed forces of the United States,
2) A spouse of a person serving in the armed forces of the United States, or
3) A person serving with, employed by, or accompanying the armed forces of the United States outside the United
States and outside the Canal Zone, Puerto Rico, Guam, and the Virgin Islands.
The parent is also known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument
and acknowledged that he/she executed the same. I certify that at the date of this certificate, I am a commissioned officer of
the armed forces of the United States having the general powers of a notary public under the provisions of Section 936 or
1044a of Title 10 of the United States Code (Public Law 90-632 and 101-510).
Subscribed and sworn to before me on this ____________________ day of ___________________________, 20______.
SIGNATURE OF OFFICER
RANK AND SERIAL NUMBER
BRANCH OF SERVICE
AD 1F (4/15)