Mother’s name
WITNESSES:
[Signature of witness]
[Printed name of witness]
[Street address of witness]
[City, state, and zip code]
[Signature of witness]
[Printed name of witness]
[Street address of witness]
[City, state, and zip code]
VERIFICATION
STATE OF [State]
COUNTY OF [Name of county]
BEFORE ME, the undersigned notary public, on this day personally appeared [Name of
parent relinquishing rights], who, being by me duly sworn on her oath, deposed and said that she is
the Affiant and that she has read the foregoing Affidavit of Relinquishment of Parental Rights and
that the statements contained therein are within her personal knowledge and are true and correct.
[Name of parent signing affidavit of relinquishment]