Fillable Consent For Contact printable pdf download

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Distribution Instructions:

CONSENT FOR CONTACT

Original: Agency/Department

Copy:

Person Signing

Please complete both sides of this form.

DESIGNATE ONE:

I am the

This form must be witnessed by either a representative of the California

■ ■

Department of Social Services (CDSS) or a California (CA) adoption agency

Birth Parent

licensed by CDSS, or notarized by a Notary Public.* If the signing of this form is

■ ■

Adult Adoptee

witnessed by a CDSS or adoption agency representative, photo identification of the

(age 18 or older)

person signing must be obtained and noted on this form. THIS FORM WILL BE

RETURNED TO YOU IF IT IS NOT WITNESSED OR NOTARIZED

To be completed by person signing consent

PART A.

■ ■

BIRTH PARENT:

By signing this form, I voluntarily give my consent to the CDSS or licensed adoption agency to disclose my name and address to my adult

biological child who was adopted so he/she may contact me.

■ ■

ADULT ADOPTEE:

By signing this form, I voluntarily give my consent to the CDSS or licensed adoption agency to disclose my name and address to my birth

parent(s) so he/she may contact me.

I understand that the CDSS does not provide search services to locate birth parents or adoptees and that these parties must contact CDSS or

the licensed adoption agency to request a Consent for Contact (AD 904) form.

I understand that the birth parent(s) and the adoptee must sign a consent before CDSS or the licensed adoption agency may disclose identifying

information and that signing this consent does not necessarily ensure that a contact will be made pursuant to Family Code Section 9204.

I understand that the law prohibits CDSS or the licensed adoption agency from soliciting, directly or indirectly, the execution of such a consent.

I understand that I should keep the CDSS or the licensed adoption agency informed of my current name and address.

I understand I have the right to rescind this consent at any time by notifying CDSS or the licensed adoption agency in writing.

NAME (PLEASE PRINT)

OTHER NAME(S) BY WHICH I HAVE BEEN KNOWN

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

(

)

SIGNATURE

DATE

PART B. To be completed by a representative of CDSS or a CA licensed adoption agency. If Part B or C is completed, do not complete Part D.

SIGNATURE OF CDSS /ADOPTION AGENCY REPRESENTATIVE

DATE

TELEPHONE NUMBER

(

)

AGENCY/DEPARTMENT NAME

ADDRESS

IDENTIFICATION OF BIRTH PARENT/ADULT ADOPTEE (SPECIFY, I.E., DRIVER’S LICENSE, PASSPORT, ETC.)

■ ■

Check if applicable. Notarized signature has been previously submitted to CDSS or a CA licensed adoption agency.

PART C.

PART D.

To be completed by a Notary Public ONLY IF Part B or C is not completed.

***COMPLETED BY Notary Public***

The Notary Public must staple the Acknowledgement document to this form and sign and date below.

SIGNATURE OF NOTARY

DATE

*Definition of Notary Public: A Notary Public is a public officer authorized by law to certify documents and to confirm your identity. Notaries

may be located at most banks and credit unions or listed in the yellow pages of your local phone directory.

AD 904 (7/11)

SEE REVERSE SIDE

Consent For Contact

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