Form Ad 887a - Statement Of Understanding - Parent Who Did Not Give Physical Custody Of The Child To The Petitioner(S)

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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 consent to adoption form.
Consenting means you agree to the permanent placement of your child with the petitioner(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 your child.
Before you sign this form and the consent to adoption form, read each of the attached statements
in consultation with the agency or California Department of Social Services‘ representative.
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 CONSENT TO ADOPTION
FORM, READ BOTH VERY CAREFULLY WITH THE AGENCY REPRESENTATIVE. BE SURE TO
ASK QUESTIONS ABOUT ANYTHING YOU DO NOT UNDERSTAND.
1. Complete this Statement of Understanding only after you have carefully thought about the
permanent placement your child and you are sure that you want your child adopted by the
petitioner(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 agency representative to explain it to you until you completely 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 agency representative’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 consent to adoption form
when it has been completed.
THIS FORM MUST BE USED WITH ONE OF THE FOLLOWING CONSENT FORMS:
AD 1A, AD 1F, AD 165 OR AD 4336
AD 887A (6/17) Parent Who Did Not Give Physical Custody (Non-Custodial Parent) of the Child to the Petitioner(s)
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