Entrustment Agreement For Permanent Surrender Of A Child Form printable pdf download

COMMONWEALTH OF VIRGINIA

Virginia Department of Social Services

ENTRUSTMENT AGREEMENT FOR PERMANENT SURRENDER OF A CHILD

(COMPLETE ONE DOCUMENT FOR EACH PARENT)

This Entrustment Agreement for Permanent Surrender of a Child, (hereinafter

referred to as the “Agreement”) is entered into this_____ day of_____, 20___

in the City/County of_________________, State of____________, between the

Mother____________, or Father___________ of,________________________

(a child under the age of eighteen) born on_______ day of_____, _____ ,

(hereinafter referred to as the “child”), and the City/County of Local Board of

Social Services, (hereinafter referred to as the “Board”).

The Mother or Father, after having been provided an opportunity for counseling

and after due consideration of alternative plans for the child, hereby voluntarily

agrees to surrender legal custody of the child, which includes all legal rights and

obligations with respect to the child, to the Board.

The Mother or Father, hereby indicates his/her understanding and

acknowledgement that the signing of the Agreement, by all parties, constitutes

his/her permanent separation from and termination of all his/her legal rights and

obligations to the child, and the child will be free from all legal obligations of

obedience and maintenance from them, from the effective date of the

Agreement.

It is understood by all parties that this Agreement may be revoked by either of the

biological parents until the child has reached ten days old and seven days have

elapsed from the signing of this Agreement. It is further understood that this

Agreement may be revoked any time prior to the termination of parental rights by

the juvenile court following a petition for approval of the entrustment agreement

§16.1-277.01, Code of Virginia.

The Mother or Father hereby grants to the Board full custody over the child, with

all rights and responsibilities to plan for the child’s future care, protection,

maintenance, including the right to place the child for adoption and to consent to

the adoption of the child pursuant to §§ 63.2-1221–1223, Code of Virginia.

Pursuant to § 63.2-1222, Code of Virginia, this Agreement is valid without the

signature of the birth father of a child born out of wedlock if the identity of the

father is not reasonably ascertainable; or the father has been given notice of the

Agreement and failed to object; or the birth father has been convicted of a

violation of subsection A of §18.2-61, §18.2-63 or subsection B of §18.2-366,

Code of Virginia, and the child was conceived as a result of the violation.

The Board hereby accepts legal custody and assumes full responsibility for the

child and agrees to care for, maintain, protect and plan for the child in a manner

conducive to the best interests of the child and the State.

Entrustment Agreement For Permanent Surrender Of A Child Form