Form Ad 926 - Statement Of Understanding - Parent Who Places The Child With The Prospective Adoptive Parent(S) Page 4
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5STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
___14. I understand the adoption agency may release identifying information from the adoption case record
only when:
a. It has been requested by certain agencies as named in law because the information is needed to
help my child;
b. My child, when he/she is an adult, and I have signed forms agreeing to the release of identifying
information so that contact can be arranged;
c. My child has reached 21 years of age, asks for my identity and I have agreed in writing to the
release of my identity and most current address in the adoption agency’s record;
d. My child has reached 21 years of age and has indicated in writing that I may have his/her adopted
name and most current address as indicated in the adoption agency’s records and I have asked for
this information; or
e. My child is under 21 years of age and the adoption agency has found that the release of my identity
and most current address as indicted in the agency’s record is justified according to law.
___15. I understand I will be able, at any time, to add information about myself to the record of the agency that
investigates the independent adoption.
___16. I understand the court may, after considering a request, release identifying information from the court’s
adoption file.
___17. I understand if I think I was deliberately not told the truth about placing my child for adoption, I have three
years after the date the adoption was completed, or within 90 days of discovery of the fraud, whichever
is earlier, to ask the court to set-aside the adoption of my child.
___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 I wish to proceed with
signing the Independent Adoption Placement Agreement (AD 924).
___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. 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.
AD 926 (7/17) PARENT WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
PAGE 4 OF 5
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