Form Ad 887 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Child To The Petitioner(S) Page 2
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6CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
STATEMENT OF UNDERSTANDING
Parent Who Gave Physical Custody of the Child to the Petitioner(s)
_____ 1. I want my child, _______________________________________________________ permanently
NAME OF CHILD
placed with __________________________________________________________ for adoption.
NAME(S) OF THE PETITIONER(S)
_____ 2. I have chosen the petitioner(s) to be the parent(s) for my child based on my
personal knowledge of at least the following information about him/her/them:
PERSONAL KNOWLEDGE OF PETITIONER(S)
First Petitioner:
Full Legal Name: ________________________________________________________________
Age: ___ Religion: _____________________ Race and Ethnicity: _________________________
Number of previous marriage: ___ Employment: ________________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
_______________________________________________________________________________
_______________________________________________________________________________
Children who do not live in the home; child support obligation for these children; and any failure to
meet child support obligations:
_______________________________________________________________________________
_______________________________________________________________________________
Any history of arrest and convictions for any crimes other than minor traffic violations:
_______________________________________________________________________________
_______________________________________________________________________________
Any removals of children from care due to child abuse or neglect:
_______________________________________________________________________________
_______________________________________________________________________________
Second Petitioner:
Full Legal Name: ________________________________________________________________
Age: ___ Religion: _____________________ Race and Ethnicity: _________________________
Number of previous marriage: ___ Employment: ________________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
_______________________________________________________________________________
_______________________________________________________________________________
Children who do not live in the home; child support obligation for these children; and any failure to
meet child support obligations:
_______________________________________________________________________________
_______________________________________________________________________________
Any history of arrest and convictions for any crimes other than minor traffic violations:
_______________________________________________________________________________
_______________________________________________________________________________
AD 887 (5/17) Parent Who Gave Physical Custody (Custodial Parent) of the Child to the Petitioner(s)
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