WITHDRAWAL OF PARENTAL CONSENT TO ADOPTION

 

On ___________ (Date), I, _____________________________, the ______________ (Father/Mother) of ____________________________, a ___________ (Male/Female) child born on _____________ (Date), consented to ________ (His/Her) adoption by ____________________________________ and _____________________________

(Adoptive Parents).

 

Henceforth, I declare the intention to revoke my consent to said adoption agreement on the grounds that the following changes in my circumstances determine it to be in the best interest of ________________________ (Child) to remain in my care and custody: _____________________________________________________________________________________________________________________________ (Description).

 

Therefore, I do hereby revoke my consent to the adoption agreement and declare said adoption agreement to be void and of no further effect.

 

In witness whereof, I have signed this instrument at ____________________________

(Place of Execution).

 

________________________________________             __________________

Signature                                                                               Date

 

This document was hereby signed in the presence of the following:

 

________________________________________             __________________

Signature                                                                               Date

 

________________________________________             __________________

Signature                                                                               Date