Form Ad 929a - Waiver Of Right To Revoke Relinquishment Agency Adoption Program
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
CDSS
WAIVER OF RIGHT TO REVOKE RELINQUISHMENT
Copy:
Birth Parent
AGENCY ADOPTION PROGRAM
Copy:
Case Record
NOTE TO BIRTH PARENT: Do not sign this form unless you want to permanently relinquish your child for adoption. By
signing this form you are ending your right to revoke the relinquishment that you signed.
On_________________________, I signed a relinquishment for adoption (“the relinquishment”) in which I agreed to
DATE
relinquish my child,__________________________________________________________________________________,
CHILD’S NAME AS SHOWN ON RELINQUISHMENT
born on _______________________, to _________________________________________________________________.
DATE OF BIRTH
NAME OF ADOPTION AGENCY
In the Statement of Understanding, I understand I have options for when my relinquishment may be filed and acknowledged
by the California Department of Social Services (CDSS). If I choose to have this relinquishment filed immediately, I
understand it may take up to 10-business days for the CDSS to file and acknowledge my relinquishment. During this period,
prior to CDSS issuing an acknowledgement, I indicate that I understand I may revoke my relinquishment.
Birth parent must initial the following statements:
______
I understand that by signing this form I am waiving the holding period and therefore making the relinquishment for
INITIAL
adoption permanent and irrevocable effective immediately, or at the close of the next business day as noted in
“Birth parent must initial one of the following statements.”
______
I understand this waiver will become void if either of the following occurs: this relinquishment is determined to be
INITIAL
invalid or the relinquishment is revoked during any holding period indicated in the Statement of Understanding I
signed.
______
I understand that by signing this form I will not be able to gain custody of my child unless, after CDSS has
INITIAL
acknowledged my relinquishment, I request that it be rescinded and the adoption agency agrees that my
relinquishment may be rescinded.
Birth parent must initial one of the following statements:
______
If signing in front of a Judicial Officer, CDSS or delegated county representative within or outside of California, I
INITIAL
understand this waiver becomes effective immediately.
______
If signing this form in front of an authorized representative of a licensed private adoption agency within or outside
INITIAL
of California, I understand I have until___________________ on _________________, ___________________,
TIME
DAY OF WEEK
MONTH/DAY/YEAR
which is the end of the next business day following the signing of the waiver, to request the waiver be withdrawn.
If I decide to withdraw this waiver, I must contact the adoption agency by phone at
(
) ________________________ or in person at ________________________________________________.
ADDRESS
DATE SIGNED
SIGNATURE OF BIRTH PARENT
- PLEASE TURN PAGE OVER -
AD 929A (12/16) This form must be used with the following forms: AD 501, AD 501A, AD 504, AD 583, AD 584, AD 591, AD 593
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