Form K.s.a. 59-2124 - Notice To Parent Or Person (Page 2 of 4) in pdf

Form K.s.a. 59-2124 - Notice To Parent Or Person Page 2

purpose.

I have fully explained that by signing such relinquishment (she)(he) is permanently

giving up all parental rights to such child and (she)(he) has stated that such is (her)(his)

intention and desire.

Dated __________, at ______ ___.m.

)

(signature of judge

ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER

STATE OF

)

) ss:

COUNTY OF

)

I, a notarial officer in and for the county and state aforesaid, certify that

, known to me to be the same person whose name is subscribed to the

foregoing relinquishment, appeared before me in person and acknowledged that the

statements made in the foregoing relinquishment are true.

Dated

.m.

(signature of notarial officer)

(SEAL, if any)

title (and rank)

[My Appointment Expires: _________ ]

ACCEPTANCE OF CHILD BY AGENCY

, the undersigned, on behalf of

, do

(name of agency)

hereby accept custody of ______________________, the above relinquished minor child.

Date

(signature and title)

CERTIFICATE OF ATTORNEY FOR RELINQUISHING MINOR PARENT

I am a licensed attorney representing

, who is a minor. I

have fully explained that by signing this relinquishment

permanently giving up all parental rights to the child and (she)(he) has stated that such is

(her)(his) intention and desire. I was present at the execution of this relinquishment.

Date

(signature of attorney)

Form K.s.a. 59-2124 - Notice To Parent Or Person Page 2