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).

 

 

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Signature                                                                                                           Date

 

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Signature                                                                                                           Date