CERTIFICATE OF RELINQUISHMENT

 

 

This certifies that the attached document, executed on ____________(Date), by _____________________________ (Name) of _____________________________ __________________________________ (Address), relinquishing custody of the child named _________________________ (Name), to _____________________________, an agency authorized to place children for adoption in a suitable home, was executed in accordance with the laws of ___________________________ (State/Commonwealth); and that the above-named child was placed for adoption with _____________________ _____________________________ (Name/Names), of _________________________ _____________________________________________ (Address), who ____________ (Has/Have) filed a petition to formally adopt the above-named child in the Court of _____________________________________________ (Name and Address of Court).

 

Approval is hereby granted for completion of the above-referenced adoption.

 

In witness whereof, I have signed this instrument in my capacity as the duly authorized representative of ________________________________________ (Agency).

 

 

________________________________________                               _____________

Signature and title of agency official                                                            Date