STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF UNDERSTANDING
INDEPENDENT ADOPTIONS PROGRAM
You will be consenting to the adoption of your child by signing the adoption placement
agreement. Consenting means you agree to place your child permanently with the
prospective adoptive parent(s) to raise as his/her/their own. When the adoption petition is
granted, you will no longer have any rights as a parent to the child.
Before you sign this form and the adoption placement agreement, read each of the attached
statements in consultation with the Adoption Service Provider.
Be sure to ask questions about any statement you do not understand. Consenting to the
adoption of your child is an extremely important decision. You should know all the facts and
consequences before making your decision.
Instructions On How to Complete This Statement of Understanding:
BEFORE YOU SIGN THIS STATEMENT OF UNDERSTANDING AND THE ADOPTION PLACEMENT
AGREEMENT, READ BOTH VERY CAREFULLY WITH THE ADOPTION SERVICE PROVIDER. BE SURE TO
ASK QUESTIONS ABOUT ANYTHING YOU DO NOT UNDERSTAND.
1.
Complete this Statement of Understanding only after you have carefully thought about
placing your child for adoption and you are sure that you want your child adopted by the
prospective adoptive parent(s) and raised by him/her/them.
2.
Read each of the statements in this document very carefully. If you do not understand a
statement, ask the Adoption Service Provider to explain it to you until you completly
understand.
3.
If you understand and agree with a statement, put your initials on the line next to the
number of that statement.
4.
If you do not agree, or if you do not understand a statement after the Adoption Service
Provider’s explanation, do not initial the line. Ask for more help and time in making your
decision.
5.
If you have initialed all the lines, sign your name on page 4 of this form.
6.
You will receive a copy of this Statement of Understanding and the adoption placement
agreement form when it has been completed.
THIS FORM IS TO BE USED WITH THE INDEPENDENT ADOPTION PLACEMENT AGREEMENT (AD 924)
FORM
AD 926 (7/17) PARENT WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
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