Form Ad 4339 Relinquishment Out-Of-State (Birth Mother/biological Father/presumed Father)
Download a blank fillable Form Ad 4339 Relinquishment Out-Of-State (Birth Mother/biological Father/presumed Father) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ad 4339 Relinquishment Out-Of-State (Birth Mother/biological Father/presumed Father) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
Out-of-State
(Birth Mother/Biological Father/Presumed Father)
Complete upper section before sending this form to an out-of-state
agency that has been requested to take the annexed relinquishment.
On this _________day of _________________20______,
the______________________________________________________
(NAME OF AGENCY)
hereby signifies its willingness to accept the annexed relinquishment
and to accept said minor child for adoption.
By
(AUTHORIZED AGENCY OFFICIAL)
I, _______________________________________ bein
____________________________________,
g the mother/father of
(NAME OF PARENT)
________
________________, in __________________________________
a minor
child, born on,
do hereby relinquish
(GENDER)
(DATE)
(CITY, STATE)
________________________________________________________________
and surrender the child for adoption to
(NAME OF AGENCY)
(
)
________________________________________________________________________________________________
(AGENCY ADDRESS)
(TELEPHONE NUMBER)
an organization licensed by the California Department of Social Services or authorized by Welfare and Institutions Code Section 16130 to
.
find homes for children and to place children in homes for adoption
I
I am not naming the prospective adoptive parent(s) for my child.
I
:
I am naming the following person(s) as the prospective adoptive parent(s)
_________________________________________________________________________________________________
(FULL NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S))
If my child is not placed in the home of the named person(s) or my child is removed from the home before the adoption is
completed, the agency will notify me. I will have 30 days from the date of the notice to rescind the relinquishment, take no
action or select another placement for my child. If I do not rescind the relinquishment within the 30-day period, the agency may
place the child in a home that the agency selects.
I fully understand that when this relinquishment is filed with and acknowledged by the California Department of Social Services, all my
rights to the custody, services and earnings of the child and any responsibility for the care and support of the child will be terminated.
________________________
_________________________________________
(DATE)
(SIGNATURE OF PARENT)
STATE OF _________________________ )
)
COUNTY OF _________________________)
________________,
, ___________________________________________________________________,
On
before me
(NAME OF AUTHORIZED OFFICIAL)
__________________________
______________________________________________________________,
of the
an
(NAME OF AGENCY)
(TITLE)
______________________,
organization licensed or otherwise approved to provide adoption services under the laws of
personally
(NAME OF STATE)
appeared _______________________________________________ , personally known to me (or proved to me on the basis of
(NAME OF RELINQUISHING PARENT)
satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed
the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the
person acted, executed the instrument.
(SIGNATURE OF AUTHORIZED OFFICIAL)
AD 4339 (12/14) (Per Family Code Section 8700[d]) REPLACES AD 4341
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal