Form Ad 842 - Alleged Father'S Consent To Adoption (Outside California In The Armed Forces)
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original: Court Record
ALLEGED FATHER’S CONSENT TO ADOPTION
Copy:
Parent
(Outside California in the Armed Forces)
Copy:
Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
PETITIONER(S)
I, ____________________________________________________________ having been alleged to be the father of
NAME OF ALLEGED FATHER
___________________________________________________________________ (Gender:
M
F) born to
NAME OF CHILD
______________________________________________________________________ on _____________________ in
NAME OF MOTHER
________________________________________________ give my full and free consent to the adoption of said child by
PLACE OF BIRTH
NAME OF PETITIONER(S)
I understand that I may revoke this consent ONLY DURING THE THIRTY (30) DAY PERIOD beginning on the date I sign
this consent and ONLY IF I HAVE NOT WAIVED MY RIGHT TO REVOKE THE CONSENT. I further understand that with
the signing of the order of adoption by the court I shall give up all my rights of custody, services, and earnings of said
child and I may not reclaim said child.
DATE
SIGNATURE OF ALLEGED FATHER
FULL ADDRESS
Witnessed By (pursuant to California Civil Code Section 1183.5)
On this the ______ day of ______________, 20____, before me _________________________________________
NAME OF OFFICER
the undersigned officer, personally appeared _________________________________________________ known to me
NAME OF ALLEGED FATHER
(or satisfactorily
proven) to be:
1) Serving in the armed forces of the United States,
2) A spouse of a person serving in the armed forces of the United States, or
3) A person serving with, employed by, or accompanying the armed forces of the United States outside the
United States and outside the Canal Zone, Puerto Rico, Guam, and the Virgin Islands.
The parent is also known to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledged that he executed the same. I certify that at the date of this certificate, I am a
commissioned officer of the armed forces of the United States having the general powers of a notary public under
the provisions of Section 936 or 1044a of Title 10 of the United States Code (Public Law 90-632 and 101-510).
Subscribed and sworn to before me on this ______day of ___________________________________, 20______.
RANK AND SERIAL NUMBER
SIGNATURE OF OFFICER
BRANCH OF SERVICE
AD 842 (3/17)
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