Form Ad 887 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Child To The Petitioner(S) Page 5

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b. The Petitioner(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.
_____ 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 __________________________________
NAME OF CONSENTING PARENT
NAME OF CHILD
understand and agree to the statements I have initialed above.
DATE
SIGNATURE OF CONSENTING PARENT
SECTION A
Complete if signed in California
I, __________________________________________________________________________, an authorized official of
NAME OF AUTHORIZED AGENCY OFFICIAL
__________________________________________________________, have witnessed the signing of this Statement
NAME OF AGENCY
of Understanding by___________________________________________________ on _________________________
DATE
NAME OF CONSENTING PARENT
SIGNATURE OF AUTHORIZED AGENCY OFFICIAL
TITLE
FULL ADDRESS
TELEPHONE NUMBER
Page 5 of 6
AD 887 (5/17) Parent Who Gave Physical Custody (Custodial Parent) of the Child to the Petitioner(s)

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