RELINQUISHMENT OF CHILD TO LICENSED AGENCY
I,____________________________________ the
__________ (Mother or Father) or We,
_________________________ and
______________________________ (Parents)
of _____________________________, a minor __________ (Male/Female) child born _____________ (Date), in
____________________________________ (Address),
being entitled to the sole custody of the above-named child, do hereby
surrender _______ (Him/Her) to ___________________________________________
(Adoption Agency), an agency duly
licensed by the _____________________________ (State/Commonwealth)
to place children in suitable homes for adoption.
I,_______________________________________ the
__________ (Mother or Father) or We,
_________________________ and ______________________________ (Parents)
fully understand that when this relinquishment agreement is filed with
__________________________________________ (Governmental
Agency) by the adoption agency named in this instrument, all
_________ (My/Our) rights to the
custody, services, and earnings of __________________________________, the
minor child, and all responsibility for __________ (His/Her) care and support will terminate and cannot be
reclaimed by __________ (Me/Us/Either).
_________________________________ ________________
Signature Date
_________________________________ ________________
Signature Date