Affidavit Of Voluntary Relinquishment Of Parental Rights - Texas District Court Page 3
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11Form: Mother’s Affidavit of Relinquishment to Licensed Child-Placing Agency
Cause Number ____________
IN THE INTEREST OF:
'
IN THE DISTRICT COURT OF
'
[CHILD'S NAME],
'
[COUNTY NAME], TEXAS
'
[A CHILD]
'
JUDICIAL DISTRICT
MOTHER'S AFFIDAVIT OF RELINQUISHMENT OF PARENTAL RIGHTS
TO LICENSED CHILD-PLACING AGENCY
STATE OF [State]
COUNTY OF [Name of county]
BEFORE ME, the undersigned Notary Public, on this day personally appeared [Mother’s
Name], who, was duly sworn and placed under oath, and in the presence of the undersigned
credible witnesses made the following statements:
“My name is [Mother’s Name]. I am
years of age. I live at: [address of mother].
My telephone number is:
. My social security number is
and my driver’s license number is
, which license is issued by [name of
State].
“I am the mother of the following [child[ren]:
Name:
[Child’s name]
Sex:
[Male or female].
Birth date:[Birthrate].
Birthplace:
[Birthplace].
Residence:
[Residence]
Social Security Number:
[Social Security Number]
Name:
[Child’s name]
Sex:
[Male or female].
Birth date:[Birthrate].
Birthplace:
[Birthplace].
Residence:
[Residence]
Social Security Number:
[Social Security Number]
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