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Irrevocable Mother'S Affidavit Of Relinquishment Of Parental Rights To A Licensed Child-Placing Agency - Texas District Court Page 5

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"I REALIZE THAT I SHOULD NOT SIGN THIS AFFIDAVIT UNTIL I

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HAVE READ AND UNDERSTOOD EACH WORD, SENTENCE, AND

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PARAGRAPH IN IT. I REALIZE THAT I SHOULD NOT SIGN THIS

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AFFIDAVIT OF RELINQUISHMENT IF THERE IS ANY THOUGHT IN

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MY MIND THAT I MIGHT SOMEDAY SEEK TO CHANGE MY MIND. I

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REALIZE THAT I SHOULD NOT SIGN THIS AFFIDAVIT OF

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RELINQUISHMENT IF I AM NOT THINKING CLEARLY BECAUSE OF

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ILLNESS, MEDICATION, MY EMOTIONAL STATE, OR ANY OTHER

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REASON. BECAUSE I REALIZE HOW IMPORTANT THIS DECISION

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IS FOR THE FUTURE OF MY CHILD(REN), I HAVE PUT MY INITIALS

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BESIDE EVERY LINE OF THIS PARAGRAPH SO THAT IT WILL

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ALWAYS BE UNDERSTOOD THAT I HAVE READ THIS AFFIDAVIT

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OF RELINQUISHMENT, UNDERSTAND IT, AND DESIRE TO SIGN IT."

SIGNED on this _______ day of ___________________, _________ at _____: _____ a.m. / p.m.

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Affiant

WITNESSES:

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Signature

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Address

Relinquishment of Parental Rights

Page 5

Affiant’s Initials _________

Irrevocable Mother'S Affidavit Of Relinquishment Of Parental Rights To A Licensed Child-Placing Agency - Texas District Court Page 5