Form Ad 4336 Presumed Father'S Consent To Adoption When Denying He Is The Biological Father
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PRESUMED FATHER’S CONSENT TO ADOPTION
Original: Court Record
WHEN DENYING HE IS THE BIOLOGICAL FATHER
Copy:
Parent
(Outside California in the Armed Forces)
Copy:
Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
PETITIONER(S)
____________________________________________________________________ being presumed by law to be the father of
I,
NAME OF PARENT
______________________________________________________________________________________(Gender:
M
F)
NAME OF CHILD
born to ______________________________________________________________ on _____________________________
in
,
NAME OF MOTHER
______________________________________________ declare that I am not the biological father of said child and give my full
PLACE OF BIRTH
and free consent to the adoption of said child by
______________________________________________________________________.
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.
I declare I am not the biological father of said child and am executing this consent to adoption solely for the purpose of promoting
the welfare and best interest of said child by facilitating said child’s adoption by petitioner(s)
.
DATE
SIGNATURE OF PARENT
FULL ADDRESS
Witnessed by (pursuant to California Civil Code Section 1183.5)
On this the ______ day of _____________, 20____, before me ________________________________________________, the
NAME OF OFFICER
undersigned officer, personally appeared ___________________________________________________________ known to
NAME OF PARENT
me (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 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
CAPACITY IN WHICH SIGNED
BRANCH OF SERVICE
AD 4336 (4/15)
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