Form K.s.a. 59-2124 - Notice To Parent Or Person

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K.S.A. 59-2124
Relinquishment to Agency
(7/1/05)
RELINQUISHMENT OF MINOR CHILD TO AGENCY
NOTICE TO PARENT OR PERSON IN LOCO PARENTIS:
This is an important legal document and by signing it you are permanently
giving up all custody and other parental rights to the child named herein. You are to
receive a copy of this document.
I,
, (mother, father, person in loco parentis) of
(name)
, a minor child, state:
1.
The child was born on
at
at
.m.
(date of birth)
(place of birth)
2.
I reside at
, County of
and State of
.
3.
I am of the age of
years and was born on
.
4.
[Neither the child nor I am a member of an Indian tribe recognized by federal law
nor an Alaskan Native recognized by federal law.] [I am a member of the
tribe,
]. [The child is a member of the
(address)
tribe,
.]
(address)
5.
I do hereby relinquish the child to
, which I understand will have
(name of agency)
full power and all the rights of a birth parent or legal guardian over the child,
including the power to place the child for adoption and give consent thereto.
6.
I wish to and understand that by signing this relinquishment I do permanently give
up all custody and other parental rights I have to such child, including the right to
receive notice of any subsequent adoption proceedings involving the child.
7.
I have read and understand the above and I am signing it as my free and voluntary
act.
Dated
, at
.m.
(signature of parent)
[Must be acknowledged before either a judge or a notary public. Choose the appropriate
acknowledgment from the two options below.]
ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT
STATE OF
)
) ss:
COUNTY OF
)
I,
, Judge of
certify that
(name and location of court)
, known to me to be the same person whose name is subscribed to the
foregoing relinquishment, appeared before me this day in person and acknowledged that
(she)(he) signed such relinquishment as (her)(his) free and voluntary act, for the specified

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