Irrevocable Mother'S Affidavit Of Relinquishment Of Parental Rights To A Licensed Child-Placing Agency - Texas District Court
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STATE OF TEXAS
§
BEFORE
ME,
the
undersigned
authority,
on
this
day
personally
appeared
_______________________, who being by me duly sworn, in the presence of the undersigned credible
witnesses made the following statements and swore that they were true:
"My name is _______________________.
My age is ____ years.
My address is
________________________________________.
My
social
security
number
is
_____________________________. I am the mother of the following child (ren):
"___________________________, a male / female child born on ____________________,
__________, at _____: _____ a.m. / p.m., in (city)_______________________, (state) _________.
"No person has been appointed or has qualified as guardian of the person(s) or estate(s) of the
child(ren).
I am not presently obligated by court order to make payments for support of the child(ren).
There is no property owned or possessed by the child(ren).
____
"The child has no presumed (legal) father, and I have executed an affidavit of status of the
child.
____
"The name of the presumed father is _________________________, and his address is
______________________________________________________.
____
"The child has a presumed father who may or may not the probable biological father and I
have executed an affidavit of status of the child.
Relinquishment of Parental Rights
Page 1
Affiant’s Initials _________
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