STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
Court Record
WAIVER OF RIGHT TO REVOKE CONSENT
Copy:
Birth Parent
INDEPENDENT ADOPTION PROGRAM
Copy:
Case Record
NOTE TO BIRTH PARENT: Do not sign this form unless you want the adopting parent(s) named below to adopt your child.
By signing this form you are ending your right to revoke the independent adoption placement agreement or consent to
adoption that you signed.
On_________________________, I signed an independent adoption placement agreement or a consent to adoption (“the
DATE CONSENT SIGNED
consent”) in which I agreed to the adoption of my child,______________________________________________________,
CHILD’S NAME AS SHOWN ON CONSENT
born on _______________________, by____________________________________________________________. In this
DATE OF BIRTH
NAMES OF PETITIONER(S)/PROSPECTIVE ADOPTIVE PARENT(S)
consent, I stated that I understood that I may revoke the consent during the 30-day period beginning on the date the consent
was signed.
Birth parent must initial the following statements:
______
I understand that by signing this form I am waiving the 30-day waiting period and therefore making the consent a
INITIAL
permanent and irrevocable consent to adoption.
______
I understand that by signing this form I will not be able to gain custody of my child unless the
INITIAL
petitioner(s)/prospective adoptive parent(s) agree(s) to withdraw the petition for adoption or the court denies the
adoption petition.
Birth parent must initial one of the following statements:
______
If signing in front of a Judicial Officer, Department or Delegated County representative within California, I
INITIAL
understand this waiver becomes effective immediately.
______
If signing in front of a Judicial Officer, Adoptions Service Provider (ASP) or an adoption agency representative
INITIAL
outside of California, I understand this waiver becomes effective immediately.
______
If signing this form in front of an ASP within California, I understand I have until___________________ on
INITIAL
TIME
_________________, ___________________, which is the end of the business day following the signing of this
DAY OF WEEK
MONTH/DAY/YEAR
waiver, to request the waiver be withdrawn. If I decide to withdraw this consent, I must contact the ASP by phone
at (
) ________________________.
SIGNATURE OF BIRTH PARENT
DATE SIGNED
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