Form Ad 927 - Statement Of Understanding - Parent Who Places The Indian Child With The Prospective Adoptive Parent(S) Page 7

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
_____ 18. I understand I will no longer be my child’s legal parent once the adoption is granted in court. This
means that:
_____ a. I will no longer be responsible for the care of my child;
_____ b. The prospective adoptive parent(s) will be the parent(s) and will be legally responsible for
caring for my child;
_____ c. I will no longer have any right to the custody, services, or earnings of my child; and
_____ d. I will not be able to reclaim my child.
_____ 19. I have received enough information about the prospective adoptive parent(s) and about my child’s
adjustment in the prospective adoptive parent(s) family, and I wish to proceed with signing the
adoption placement agreement form.
_____ 20. I have carefully thought about the reasons for keeping or placing my child for adoption. I have
decided that placing my child with the prospective adoptive parent(s) for adoption is in the best
interest of my child. I have read and understand this Statement of Understanding and the
adoption placement agreement forms. I do not need any more help or time to make my decision. I
have decided to place my child for adoption and consent to the adoption of my child by the
prospective adoptive parent(s) and I am signing this freely and willingly.
I,_______________________________________, mother/father of _______________________________,
NAME OF PLACING PARENT
NAME OF CHILD
understand and agree to the statements I have initialed above.
DATE
SIGNATURE OF PLACING PARENT
SECTION A
Complete SECTION A and B if signed in or out of California
, ____________________________________________________, have witnessed the signing of this
I
Statement of Understanding by ___________________________________on _____________, I am :
A representative of ___________________________________, a California licensed
DATE
private adoption agency.
I
An individual California Adoption Service Provider (ASP).
I
A representative of ___________________________________, an adoption agency licensed
I
or otherwise approved under the laws of the state of ___________________________ the state
where the adoption placement agreement is being signed.
An individual licensed or otherwise certified as a clinical social worker under the laws of
____________________________, the state where the adoption placement agreement is being
I
signed.
Independent counsel for the placing parent(s) serving as an ASP, pursuant to Family Code
Section 8502(b) and 8801.5(e).
I
DATE
SIGNATURE OF WITNESS
AD 927 (7/17) PARENT OF INDIAN CHILD WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
PAGE 7 OF 8

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