Form Ad 900 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Indian Child To The Petitioner(S) Page 8

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
_____ 20. I have received enough information about the petitioner(s) and about my child’s adjustment in the
petitioner(s) family, and I wish to proceed with signing the consent to adoption form.
_____ 21. I have carefully thought about the reasons for keeping or consenting to the adoption of my child. I
have decided that consenting to the adoption of my child by the petitioner(s) is in the best interest
of my child. I have read and understand this Statement of Understanding and the consent to
adoption form. I do not need any more help or time to make my decision. I have decided to
consent to the adoption of my child by the petitioner(s), and I am signing this freely and willingly.
I, __________________________________, mother/father of ____________________________________
understand and agree to the statements I have initialed above.
SIGNATURE OF CONSENTING PARENT
SECTION A
Complete SECTION A and C if signed in California
I, ________________________________________________________________, an authorized official of
__________________________________________________________, have witnessed the signing of this
NAME OF AGENCY
Statement of Understanding by ____________________________________________ on _____________.
SECTION B
Complete SECTION B and C if signed outside of California
I, ________________________________________________________________, an authorized official of
NAME OF AUTHORIZED AGENCY OFFICIAL
______________________________________________________, an organization licensed or otherwise
approved to provide adoption services under the laws of _______________, have witnessed the signing of
this Statement of Understanding by _______________________________________ on _______________.
DATE
PAGE 8 OF 9
AD 900 (7/17) PARENT WHO GAVE PHYSICAL CUSTODY (CUSTODIAL PARENT) OF THE INDIAN CHILD TO THE PETITIONER(S)

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