Entrustment Agreement For Permanent Surrender Of A Child Form (Page 2 of 2) in pdf

Entrustment Agreement For Permanent Surrender Of A Child Form Page 2

In witness whereof, all parties received a copy of the Agreement pursuant to §

63.2-1222, Code of Virginia.

__________________________________________ __________

MOTHER or FATHER

DATE

__________________________________________ ___________

REPRESENTATIVE OF THE BOARD

DATE

STATE OF VIRGINIA

COUNTY/CITY OF ______________________________________, ss:

I, ____________________________________________________, a notary

public in and for the County/City aforesaid, do certify that

__________________________________________________,whose name is

signed first to the writing above, has acknowledged the same before me on this

day of___________, 20________ .

_________________________________________________, Notary Public

My commission expires: _____________________________.

STATE OF VIRGINIA

COUNTY/CITY OF ______________________________________, ss:

I, ____________________________________________________, a notary

public in and for the County/City aforesaid, do certify that

__________________________________________________, whose name is

signed last to the writing above, has acknowledged the same before me on this

day of_____________, 20_________ .

_________________________________________________, Notary Public

My commission expires: _____________________________.

032-02-0024-04-eng (08/06)

Entrustment Agreement For Permanent Surrender Of A Child Form Page 2