Form Ad 929 Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program Page 2
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1
2WAIVER OF RIGHT TO REVOKE CONSENT
INDEPENDENT ADOPTION PROGRAM - CONTINUED
THIS SECTION TO BE COMPLETED BY WITNESS
I,______________________________________________________, have witnessed the signing of this Waiver of Right to
Revoke Consent by ___________________________________________on___________________________________
DATE
BIRTH PARENT
in________________________________, __________________________________________.
CITY
STATE
(See Family Code Section 8814.5)
Witness in California: I am
■ ■
A representative of the California Department of Social Services.
Date of interview with birth
parent:____________________________.
■ ■
A representative of the____________________________________________________, a delegated
county adoption agency. Date of interview with birth parent:____________________________.
■ ■
A judicial officer of _______________________________ California court of record.
■ ■
An ASP. (The waiver may be signed in the presence of an ASP only if the birth parent or parents are
represented by independent legal counsel). I have informed the birth parent or parents of the time period that
he/she/they
may
request
the
waiver
be
withdrawn.
The
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).
Witness outside of California: I am
■ ■
A representative of_____________________________________________, an adoption agency licensed or
otherwise approved under the laws of the state of_________________________________, the state where
the waiver of right to revoke consent is being signed.
■ ■
An individual licensed or otherwise certified as a clinical social worker under the laws
of______________________________, the state where the waiver of right to revoke consent is
being signed.
■ ■
A judicial officer of the___________________________________________, a court of record in the state
of_____________________________, the state where the waiver of right to revoke consent is being signed
and where the birth parent is represented by independent legal counsel.
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 California ASP.
I am the independent legal counsel who represents the birth parent and I have reviewed this waiver
NAME
SIGNATURE
PHONE NUMBER
ADDRESS
(
)
AD 929 (8/11)
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