REVOCATION OF RELINQUISHMENT
On _______________ (Date),
_____________________, the ________________ (Father/Mother)
of _______________________, a minor ___________ (Male/Female) child, relinquished custody of said child to
the _______________________________ (Name of
Agency) located at ______________________________________________ (Address), in order that the above-named
agency might place __________ (Him/Her)
with suitable adoptive parents.
The ______________________ (Name of Agency) and
________________________, the ______________ (Father/Mother)
of _______________________, the minor ___________ (Male/Female) child, now desire to revoke the agreement
relinquishing custody of the child.
Thereupon, both parties consent to revoke the
agreement to relinquish custody of the above-named minor child and to declare
the agreement to be void and of no further effect.
Signature of Parent Date
Mother) of _________________________ (Name of Child)
____________________________________________ (Name and Address of Agency)
Signature and Title of Agency Official Date