Form Ad 929a Waiver Of Right To Revoke Relinquishment Agency Adoption Program Page 2
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1
2WAIVER OF RIGHT TO REVOKE RELINQUISHMENT
AGENCY ADOPTION PROGRAM - CONTINUED
THIS SECTION TO BE COMPLETED BY WITNESS
I,______________________________________________________, have witnessed the signing of the Waiver of Right to
Revoke Relinquishment by_______________________________________on__________________________________,
BIRTH PARENT
DATE
in________________________________, ___________________________________________.
CITY
STATE
(See Family Code Section 8700.5)
Witness: I am
A representative of the CDSS. Date of interview with birth parent: ____________________________.
A representative of the____________________________________________________, a delegated
NAME OF AGENCY
county adoption agency in California. Date of interview with birth parent: __________________________.
A judicial officer of _______________________________ California court of record: legal counsel, if birth
parent is represented by independent legal counsel.
Date of interview with birth parent:_________________________ .
A judicial officer of the ___________________________________________, a court of record in the state of
__________________________________, the state where the Waiver of Right to Revoke Relinquishment is
being signed and where the birth parent is represented by independent legal counsel. Date of interview with
birth parent: ____________________________.
An authorized representative of a licensed adoption agency approved under the laws of the state of
_____________________________________________, the state where the waiver of rights is being
signed. (The waiver may be signed in the presence of an authorized representative only if the birth parent
or parents are represented by independent legal counsel.) I have informed the birth parent or birth parents
of the time period that he/she/they may request the waiver be withdrawn. This interview was conducted by
_________________________________, the independent legal counsel for the birth parent(s), on
______________________________. (A copy of the independent legal counsel’s certification is attached.)
NOTE:
The waiver may be signed outside of California only if the birth parent resides outside of California or is located
outside of California for an extended period of time unrelated to the adoption.
NAME OF WITNESS
SIGNATURE OF WITNESS
ADDRESS:
TELEPHONE
(
)
To be completed by independent legal counsel for the birth parent(s) when signing in front of a licensed adoption
agency within or outside of California or judicial officer.
I am the independent legal counsel who represents the birth parent and I interviewed the birth parent
on:________________________ prior to his/her signature. I have reviewed the waiver with the birth parent, counseled
them about the intended nature of the waiver and have delivered to the birth parent and the adoption agency a certificate
attesting to these facts. My ability to provide independent legal counsel to my client is attached here to.
NAME
SIGNATURE
PHONE NUMBER
ADDRESS
(
)
AD 929A (7/13)
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